ij^lrr^^ 


THE  LIBRARIES 

COLUMBIA  UNIVERSITY 


HEALTH  SCIENCES  L| 

LIBRARY  H 

1 
1 
1 


GUNSHOT  INJURIES 


HOW  THEY  ARE  INFLICTED 
THEIR  COMPLICATIONS  AND  TREATMENT 


BY 

COLONEL  LOUIS  A.  LAGARDE 

UNITED    STATES    ARMY    MEDICAL   CORPS   (Retired) 

LATE     COMMANDANT    AND  PROFESSOR  OF    MILITARY     SURGERY,   U.   S.   ARMY 

MEDICAL  school;  PROFESSOR  OF  MILITARY  SURGERY,  MEDICAL 

DEPARTMENT,   N.     Y.    UNIVERSITY,   ETC.,   ETC- 


Prepared  under   the   Direction   of  the   Surgeon 

General  United  States  Army  and  Published 

by  Authority  of  the  Secretary  of  War 


LIBRARY  OF  THE 

rn^tV^^'  ASSOCIATION, 

COLUMBIA  LfN!VERSlTV 
NRW  YORK 

NEW   YORK 

WILLIAM  WOOD  AND  COMPANY. 

MDCCCCXIV 


7^  T^  I  "^ 


\ 


Copyright,    1914, 
By  WILLIAM  WOOD  AND  COMPANY 


THE . MAPLE . PRESS • YORK- PA 


PREFACE 

The  necessity  for  a  book  on  Gunshot  Injuries  for  the  use  of  the 
mihtary  services  and  the  American  surgical  profession  was  not  appar- 
ent until  very  recently.  After  the  conclusion  of  our  great  Civil  War 
the  volumes  of  Otis^  supplied  all  the  wants  of  the  profession  in  this 
particular  branch  of  surgery.  The  matter  in  the  volumes  referred  to 
was  rich  in  variety  and  so  well  suited  to  the  requirements  of  the 
clinician  and  students  of  surgical  literature  that  it  became  the  refer- 
ence work  of  the  medical  profession  the  world  over.  But  the  subject 
of  Gunshot  Injuries  as  a  whole  has  been  so  modified  by  radical  changes 
in  the  armament  of  the  nations  and  the  results  in  wounds  by  firearms 
have  been  so  modified  by  modern  methods  of  treatment,  that  the  works 
of  Otis  and  his  contemporaries  have  now  been  entirely  superseded  as 
far  as  practical  surgery  is  concerned. 

The  demand  of  the  military  and  civil  surgeon  now  requires  a  presen- 
tation of  the  important  subject  of  gunshot  injuries  as  inflicted  by  a 
new  armament,  and  treated  after  the  methods  of  modern  surgical  prac- 
tice. The  characteristic  features  of  the  wounds  by  the  former,  and  the 
results  attained  in  them  by  the  latter  have  entirely  revolutionized 
military  surgery,  so  that  the  wounds  by  firearms  of  fifty  years  ago  and 
the  results  of  the  treatment  then  in  vogue  form  no  guide  for  a  study  of 
the  subject  to-day. 

Some  authors  on  military  surgery  have  sought  from  the  time  fire- 
arms were  first  used  to  treat  gunshot  injuries  in  war,  as  a  specialty  in 
surgery,  apart  from  the  class  of  gunshot  wounds  the  civil  practitioner 
is  called  upon  to  treat  in  civil  practice.  A  careful  study  of  the  subject 
will  show  that  there  has  been  but  little  difference  in  the  character 
of  the  large  majority  of  the  wounds  from  these  sources.  Wounds  ob- 
served in  the  two  conditions  mentioned  have  for  the  most  part  been 
caused  by  similar  weapons.  In  the  evolution  of  firearms  the  rifle  of 
the  sportsman  has  differed  but  little  from  the  military  rifle,  and  the 
same  may  be  said  of  pistols  and  revolvers,  except  that  in  civil  prac- 
tice wounds  were  more  often  inflicted  by  bullets  having  less  weight 
and  cahber,  possessed  with  lower  velocity,   and  animated  by   less 

1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Parts  I,  II,  and 
III,  Surgical  Vols.,  by  Geo.  A.  Otis,  Surg.,  U.  S.  A. 


iv  PREFACE 

energy.  This  does  not  apply  to  the  days  of  the  code  duello,  because 
then  the  weapon  used  in  personal  combat  was,  ballistically  speaking, 
similar  to  the  military  hand  weapon  of  that  day  and  the  character 
of  the  wounds  inflicted  in  military  and  civil  practice  was  the  same. 

In  our  day  reduced  caliber  rifles  employing  steel  mantle  projec- 
tiles used  by  armies  and  the  sporting  world  alike,  serve  to  maintain 
the  similarity  in  wounds  seen  by  the  military  and  civil  surgeon,  and 
since  the  automatic  hand  weapons  of  the  pistol  and  revolver  class 
using  steel  mantle  projectiles  are  coming  into  use  in  the  civil  popula- 
tion and  the  mihtary  services,  the  similarity  of  the  wounds  seen  in 
peace  and  war  will  be  further  emphasized. 

In  recent  wars  the  use  of  hand  grenades,  bombs  and  other  devices 
which  are  made  to  burst  by  the  agency  of  high  explosives  is  becoming 
common,  but  the  civil  practitioner  has  opportunities  to  see  the  lacer- 
ated wounds  from  nitroglycerin  and  all  of  its  modifications  now  ex- 
tensively used  in  engineering  projects  everywhere  so  that  the  charac- 
ter of  these  wounds  is  not  pecuhar  to  the  military  service. 

The  difference  in  environment  has  probably  done  more  than  any 
other  one  thing  to  cause  the  earlier  mihtary  surgeons  to  regard  gun- 
shot injuries  in  war  as  a  special  branch  of  surgery,  and  that  came 
largely  from  the  fact  that  military  surgery  is  mostly  made  up  of 
emergency  surgery.  But  during  these  industrial  times  the  practice 
of  the  civil  surgeon  is  to  a  large  extent  made  up  of  emergency  surgery, 
and  like  his  confreres  in  military  practice  he  is  well  versed  in  all  the 
resources  of  first-aid  to  the  injured. 

In  great  wars  the  military  surgeon  has  exceptional  opportunities 
to  observe  gunshot  wounds  of  all  kinds.  Here  again  we  find  that 
gunshot  injuries  form  a  branch  of  surgery  common  to  the  military  and 
civil  surgeon  because  armies  are  never  provided  with  sufficient  relief 
personnel  in  peace  to  meet  all  the  exigencies  in  war.  As  example  we 
find  that  the  civilian  surgeons  out-numbered  the  regular  medical  of- 
ficers in  the  Spanish-American  in  the  ratio  of  1  to  6,  and  in  the  great 
Civil  War  1  to  66.  When  war  is  declared  assistance  has  to  come  from 
the  medical  gentlemen  in  civil  life  and  history  shows  that  their  services 
are  more  than  welcome,  and  that  they  have  always  responded  most 
willingly  to  their  country's  call  in  times  of  stress. 

In  the  following  chapters  the  author  has  as  far  as  possible  pre- 
sented the  characteristic  features  of  wounds  by  the  old  armament  in 
preantiseptic  times,  and  compared  these  with  the  results  of  gunshot 
injuries    by    modern    arms    in    the    Spanish- American,    Anglo-Boer, 


PREFACE  V 

Russo-Japanese  and  Turko-Balkan  Wars.  He  has  also  availed  himself 
of  the  character  of  wounds  by  firearms  in  civil  life  and  their  results  as 
compared  to  similar  wounds  in  the  military  service.  Like  observations 
have  also  been  made  to  a  less  extent  on  wounds  by  different  kinds  of 
rifles,  pistols  and  revolvers  on  animals,  experimental^  and  in  the  hunt. 

There  is  a  medico-legal  aspect  involved  in  the  subject  of  gunshot 
injuries  that  is  not  treated  as  a  rule  in  books  on  military  surgery,  but 
we  know  that  the  military  sm'geon  is  often  called  into  courts  to 
testify  in  cases  having  a  medico-legal  bearing  and  that  it  would  appear 
to  be  his  duty  as  much  as  that  of  the  civil  surgeon  to  acquaint  himself 
with  this  part  of  the  subject,  hence  the  chapter  on  The  Medico-legal 
Phases  of  Gunshot  Wounds. 

The  bulk  of  the  matter  in  the  following  chapters  has  been  culled 
from  lectures  which  for  more  than  twelve  years  have  formed  the  basis 
for  teaching  in  civil  and  military  medical  schools — the  method  of 
teaching  in  the  one  has  differed  but  little  from  that  employed  in  the 
other. 

The  chapter  on  Field  X-ray  Apparatus  has  been  confined  to  a 
discussion  of  types  of  apparatus  which  have  been  found  most  suitable 
for  field  work.  We  believe  that  good  radiography  can  only  be  done 
by  trained  radiographers;  especially  is  this  so  under  the  unfavorable 
conditions  which  obtain  dui'ing  active  service  and  for  this  reason  all 
description  of  radiogi^aphic  technique  has  been  omitted  from  this 
work.  For  the  entire  rendition  of  this  chapter  we  are  indebted  to 
Captains  Henry  F.  Pipes,  W.  A.  Duncan  and  Arthur  C.  Christie, 
Medical  Corps,  U.  S.  Arm3^ 

The  first  chapter  was  revised  in  the  office  of  the  Chief  of  Ordnance 
and  the  part  of  the  chapter  on  Ballistics  was  written  in  that  office 
under  the  supervision  of  Colonel  John  T.  Thompson,  0.  D.,  U.  S. 
Array. 

The  remaining  chapters  were  revised  in  the  office  of  the  Surgeon 
General  by  Lt.  Col.  F.  A.  Winter,  M.  C,  U.  S.  A.,  to  whom  I  am  in- 
debted for  valuable  assistance. 

L.  A.  L. 
Washington,  January  1,  1914. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/gunshotinjuriesOOIaga 


CONTENTS 

CHAPTER  I 

Technical  Considerations 


Page 


1.  Definition   of   a   Gunshot    Wound.        2.    Firearms.       3.  Explosives. 

4.  Projectiles.     5.  Ballistics 1-32 

CHAPTER  II 

Characteristic  Lesions  Caused  by  Projectiles 

1.  Wounds  by  Military  Rifles  in  Recent  Wars.  2.  Effects  of  the  Pointed, 
Spitz,  or  Bullet  "S"  on  Cadavers,  Large  Animals,  and  in  the  Turko- 
Balkan  War.  3.  The  Stopping  Power  or  Shock  Effects  of  Bullets 
from  Rifles,  Pistols  and  Revolvers.  4.  Explosive  Effects  of  Rifle 
Bullets  Explained.  5.  Woundsby  Projectiles  from  the  Artillery  Arms. 
6.  Wounds  from  Pistols,  Revolvers,  Shotguns,  and  Target  Rifles   .     33-113 

CHAPTER  III 

Symptoms  of  Gunshot  Wounds 

1.  (a)  Pain,   (b)  Shock,  (c)  Hemorrhage,  and  (d)  Thirst.     2.     Treatment 

of  Shock 114-121 

CHAPTER  IV 

Infection  of  Gunshot  Wounds 

1.  Infection  in  Wounds.  2.  Poisoned  Wounds.  3.  Tetanus  and  Toy- 
pistol  Tetanus     122-139 

CHAPTER  V 

Treatment  of  Gunshot  Wounds 

1.  Arrest  of  Hemorrhage.  2.  Prevention  of  Infection.  3.  Iodine  as  a 
Disinfectant  in  Military  Surgery.  4.  The  Value  of  Immobolization 
in  all  Gunshot  Wounds.  5.  Summary  of  the  Measures  to  Prevent 
Infection  in  Gunshot  Wounds.  6.  Examination  of  Gunshot 
Wounds.     7.  Remote  Treatment  of  Gunshot  Wounds 140-154 

CHAPTER  VI 

Gunshot  Wounds  of  the  Head,  Face  and  Neck 

Head:  1.  Wounds  of  the  Scalp.  2.  Wounds  of  the  Skull  without  Brain 
Lesion.  3.  Fracture  of  the  Outer  Table.  4.  Fracture  of  the  Inner 
Table.     5.  Fracture  of  the  Skull  with  Brain  Lesion.     6.  Remote 

vii 


Vlll  CONTENTS 

Page 
Effects  in  Head  Wounds.     7.   Hernia  Cerebri.     8.  Abscess  of  Brain. 
9.  Lodged  Missiles  in  Brain. 

Face:  1.  Wounds  of  the  Ear.  2.  Wouds  of  tbe  Orbit.  3.  Wounds  of 
the  Nose.  4.  Wounds  of  Malar  Bones.  5.  Wounds  of  the  Upper- 
jaw.     6.  Wounds  of  the  Lower-jaw. 

Neck:  1.  Wounds  of  the  Neck  without  Injury  to  the  Cervical  Vertebrae, 
List  of.  2.  Comphcations  in  Wounds  of  the  Neck.  3.  Wounds  of 
Blood-vessels.  4.  Wounds  of  Nerves.  5.  Wounds  of  the  Air- 
passages    155-199 

CHAPTER  VII 

Gunshot  Wounds  of  the  Spine 

1.  FataUty  of  Different  Regions  in  Wounds  of  the  Spine.  2.  Concussion 
of  Cord  by  Large  and  Small  Caliber  Bullets.  3.  Contusion  of  the 
Cord.  4.  Hemorrhage  of  the  Cord.  5.  Treatment  of  Gunshot 
Injuries  of  the  Spine 200-213 

CHAPTER  VIII 

Gunshot  Wounds  of  the  Chest 

1.  Non-penetrating.  2.  Contusions.  3.  Laceration  and  Penetration  of 
the  Chest  Wall.  4.  Humane  Character  of  Gunshot  Wounds  of 
Chest  by  New  Armament.  5.  Symptoms  and  Complications.  6. 
Treatment  of  Gunshot  Wounds  of  the  Chest.  7.  Wounds  of  the 
Chest  with  Fracture.     8.  Wounds  of  Heart  and  Pericardium   .    .    .   214-225 

CHAPTER  IX 

Gunshot  Wounds  of  the  Abdomen 

1.  Contusions.  2.  Non-penetrating  Wounds.  3.  Penetrating  Wounds 
without  Visceral  Lesions.  4.  Perforating  Wounds  of,  with  Visceral 
Lesions.  5.  Statistics  of  Gunshot  Injuries  of  Abdomen.  6.  Treat- 
ment of  Penetrating  and  Perforating  Wounds.  7.  Indications  for 
Operation.  8.  Wounds  of  the  Small  Intestine.  9.  Wounds  of  the 
Stomach.  10.  Wounds  of  the  Large  Intestine.  11.  Wounds  of  the 
Sigmoid  Flexure  and  Rectum.  12.  Wounds  of  the  Liver  and  Gall- 
bladder. 13.  Wounds  of  the  Pancreas.  14.  Wounds  of  the  Spleen. 
15.  Wounds  of  the  Kidney.  16.  Wounds  of  the  Adrenal  Gland.  17. 
Wounds  of  the  Urinary  Bladder.  18.  Wounds  of  the  External 
Genital  Organs 226-274 

CHAPTER  X 

Injury  to  Blood-vessels  and  Nature  op  the  Lesions 

1.  Results  of  Injury  to  Blood-vessels.  2.  Traumatic  Aneurysms.  3. 
Aneurysmal  Varix  and  Varicose  (Arterio-venous)  Aneurysm.  4. 
Injury  to  Peripheral  Nerves 275-288 


CONTENTS  IX 

Page 

CHAPTER  XI 

Gunshot  Wounds  of  Joints 

1.  Humane  Features  of  Joint  Wounds  by  the  New  Armament.  2. 
Mortality  from  Wounds  of  Joints,  in  the  last  five  Wars.  3.  Wounds 
of  Joints  with  Lodged  Missiles.  4.  Treatment  of  Wounds  of  Joints. 
5.  Special  Joints,  Wounds  of 289-331 

CHAPTER  XII 

Gunshot  Injuries  of  the  Diaphyses  of  the  Long  Bones 

1.  Contusions.  2.  Simple  Fractures.  3.  Compound  fractures.  4.  Treat- 
ment of  Gunshot  Fractures  of  the  Humerus.  5.  Gunshot  Frac- 
tures of  the  Forearm.  6.  Wounds  of  the  Hand.  7.  Wounds  of  the 
Shaft  of  the  Femur.  8.  Fractures  of  the  Tibia  and  Fibula.  9. 
Wounds  of  the  Bones  of  the  Foot 332-366 

CHAPTER  XIII 

Medico-legal  Phases  of  Gunshot  Wounds 

1.  Diagnosis  of  a  Wound  Caused  by  Firearms.  2.  At  what  Distance 
was  the  Firearm  Discharged.  3.  Was  the  Wound  Inflicted  before 
or  after  Death.  4.  Is  the  Wound  Dangerous  to  Life.  5.  The 
Practitioner's  Liability  in  Case  of  Infection.  6.  How  was  the 
Wound  Inflicted?  7.  Was  it  Accident,  Suicide  or  Homicide?  8. 
Identity  of  the  Individual  by  the  Flash  of  the  Firearm.  9.  Self- 
inflicted  Non-fatal  Wounds.  10.  At  what  Time  was  the  Firearm 
Discharged.     11.  Was  the  Projectile  Jacketed  or  not? 367-381 

CHAPTER  XIV 

Field  X-ray  Apparatus 

1.  Importance  of  Radiography  in  Military  Surgery.     2.  The  Particular 

Kind  of  Machine  best  adapted  to  Field  Work 382-390 


GUNSHOT  WOUNDS 

CHAPTER  I 

Technical  Considerations 

1.  Definition  of  a  Gunshot  Wound;    2.  Firearms;    3.  Explosives; 
4.  Projectiles;    5.  Ballistics 

1.  DEFINITION 

The  term  gun  has  descended  to  us  from  those  earlier  days  of  the 
use  of  firearms  when  large  guns  like  cannons,  mortars,  and  the  hand 
cannon  carried  by  two  men,  were  the  only  weapons  used  in  war. 
Hand  weapons  like  the  musket,  rifle,  carbine,  pistol  and  revolver  were 
unknown  until  the  lapse  of  several  centuries,  hence  the  phrase  ''gun- 
shot wounds, "  which  is  now  employed  to  designate  the  injuries  caused 
by  firearms.  The  surgical  term — gunshot  wound — has  a  wider 
application  for  the  military  surgeon  than  that  usually  understood  by 
the  surgeon  in  civil  life.  For  the  latter  the  term  includes  those  wounds 
occurring  in  civil  communities  from  missiles  fired  from  portable 
firearms,  viz. :  weapons  like  shotguns,  sporting  rifles,  pistols,  revolvers, 
toy  pistols,  air-guns,  etc.  Such  weapons  propel  missiles  like  bullets 
of  varying  caliber,  lead  pellets,  powder  grains,  with  and  without  wads, 
by  means  of  a  sudden  explosive  force  resulting  from  the  generation  of 
large  volumes  of  gases  which  are  liberated  by  igniting  explosive 
materials. 

Under  the  term  gunshot  wounds  the  military  surgeon  includes 
in  his  battle  returns  all  wounds  resulting  from  the  effects  of  any 
explosive  force.  For  instance,  to  him  the  wound  caused  from  a  splinter 
of  wood  detached  by  a  fragment  of  shell  is  as  much  a  gunshot  wound  as 
the  injury  which  might  have  resulted  from  the  shell  fragment  itself. 
The  same  may  be  said  of  the  wounds  that  result  from  an  explosion  or 
any  explosive  contrivance  of  whatever  kind  such  as  a  bomb,  terrestrial 
mine,  torpedo,  or  any  engine  or  implement  used  in  war.  In  medico- 
military  parlance  any  missile  that  is  set  in  motion  with  suffi- 
cient velocity  by  a  sudden  expansive  force  may  cause  a  gunshot 
wound. 

1 


GUNSHOT   WOUNDS 


2.  FIREARMS 


For  a  proper  estimate  of  the  nature  and  character  of  gunshot  in- 
juries as  the  subject  appears  in  our  Hterature,  the  surgeon  should 
familiarize  himself  with  the  evolution  of  firearms,  their  projectiles,  and 
the  explosives  which  have  been  employed  for  the  purpose  of  inflicting 
injuries  from  the  earliest  times.  He  should  further  have  knowledge 
of  the  mechanics  of  projectiles  as  far  as  that  part  of  the  subject  may 
relate  to  motion,  velocity,  and  energy. 

In  discussing  firearms  proper  it  is  only  necessary  for  our  purpose  to 
review  briefly  the  evolution  of  weapons,  giving  the  name  and  the 
salient  features  of  each,  reserving  greater  space  for  the  more  important 
subjects  of  projectiles,  the  mechanics  of  projectiles,  etc. 

Firearms  and  Other  Machines  used  in  War. — Firearms  of  the 
military  class  are  divided  into  those  of  the  artillery  and  the  so-called 
hand-weapons.  Under  the  former  will  be  included  large  guns,  field 
guns,  and  other  engines  employed  in  war. 

Large  Guns. — These  are  breech-loading  rifled  guns,  the  largest 
and  heaviest  types  being  used  on  large  war  vessels .  and  in  seacoast 
fortifications.  The  longest  of  these  guns  is  about  50  feet,  the  weight 
about  130  tons  and  the  caliber  about  16  inches.  They  fire  shot  and 
shell,  made  from  the  hardest  steel,  weighing  about  2400  pounds, 
with  an  initial  velocity  of  about  2250  f.s.  These  large  projectiles 
penetrate  steel  armor  21  inches  in  thickness  at  a  distance  of  5000 
yards.     These  heavy  guns  have  various  calibers  down  to  3  inches. 

Mobile  Artillery  and  Siege  Guns. — These  vary  in  caliber  from  3 
inches  to  6  inches.  The  most  common  of  the  field  guns  is  the  3-inch 
breech-loading  steel  rifle  which  accompanies  an  army  in  the  field, 
while  the  heavy  field  or  siege  cannon,  such  as  the  6-inch  howitzer  and 
4.7-inch  gun,  are  used  principally  against  fortified  positions.  All 
these  types  employ  shell  and  shrapnel. 

Howitzers. — These  are  cannon  of  3.8-inch,  4.7-inch  and  6-inch 
caliber  in  our  army,  but  shorter  than  the  guns  of  the  same  calibers. 
They  fire  projectiles  at  lower  velocities  and  at  higher  angles  than  guns. 

Mortars. — Are  also  cannon  shorter  than  the  guns  or  howitzers  and  are 
fired  at  lower  velocities  and  with  higher  elevations  than  the  latter. 
They  are  principally  used  to  throw  projectiles  over  fortified  places  or 
intervening  obstacles  into  fortifications  or  bodies  of  troops  which  can- 
not be  reached  by  ordinary  gunfire,  or  upon  the  decks  of  vessels. 

Machine  Guns. — This  class  of  guns  is  used  by  all  armies  under 


FIREARMS  6 

different  names.  In  our  service  we  now  employ  the  Automatic  Machine 
Rifle,  cal.  .30  (Benet-Mercie  system),  which  fires  the  infantry  rifle 
ammunition  at  great  speed. 

Hand  Weapons. — This  is  a  class  of  firearms  to  which  the  term  hand- 
weapon  has  been  given  because  they  are  carried  by  the  soldier  and 
fired  from  the  hand  or  shoulder.  This  class  includes  the  military  rifle, 
the  carbine,  revolver  and  pistol. 

The  Military  Rifle. — This  weapon  is  now  carried  by  all  soldiers 
of  the  line  except  field  artillery,  viz.:  cavalry,  infantry,  the  marines 
and  sailors.  It  represents  the  perfected  weapon  which  has  been 
evolved  in  the  process  of  gun-making  from  the  hand-cannon  to  the 
magazine  breech-loading  rifle.  In  order  to  properly  appreciate  the 
significance  of  the  military  rifle,  the  following  summary  of  the  dif- 
ferent stages  in  the  development  of  firearms  will  be  of  assistance : 

Hand  Cannon. — These  guns  originated  in  the  East,  from  which  they 
were  introduced  into  Europe  in  1446.  They  were  the  first  portable 
firearms  of  which  we  have  any  record.  The  hand-cannon  was  a  small 
cannon  carried  by  two  men  and  was  fired  from  a  rest  on  the  ground 
and  later  from  two-forked  sticks. 

Hand  Gun. — The  hand  gun  followed  the  hand-cannon;  the  barrel 
was  longer  and  was  made  of  brass  fixed  in  a  wooden  stock,  and  like  its 
predecessor,  was  fired  by  a  lighted  match  applied  by  the  hand  to  a 
touch  hole  at  the  rear  end  of  the  barrel.  The  projectiles  were  made  of 
stone,  iron,  or  lead,  and  the  recoil  was  received  by  a  breast  plate  in- 
stead of  the  shoulder. 

Match  Lock. — The  hand  gun  was  followed  by  the  match  lock, 
which  was  provided  with  a  swinging  cock  holding  a  burning  taper. 
The  latter  was  gradually  approached  to  the  powder  in  the  firing-pan 
around  the  touch  hole,  by  pressing  a  trigger,  underneath,  with  the 
finger.  These  weapons  were  used  in  war  for  nearly  two  hundred  years, 
when  guns  with  more  complicated  devices  were  adopted. 

Wheel  Lock. — This  is  a  gun  invented  in  Germany  about  1515. 
The  powder  in  the  pan  was  ignited  by  sparks,  which  emitted  from 
sulphurous  pyrites  resting  against  a  rapidly  revolving  wheel  set  in  motion 
by  pressing  the  trigger. 

The  Snap  Haunce  Gun. — This  gun  followed  the  wheel  lock.  It 
derives  its  name  from  a  pecking  hen.  In  this  the  wheel  was  replaced 
by  a  cock  which  struck  a  steel-faced  cover  over  the  pan.  It  employed 
pyrites  to  produce  the  spark  and  it  preceded  the  use  of  the  more 
effective  flint  lock.   The  operation  of  firing  with  all  the   preceding 


4  GUNSHOT   WOUNDS 

weapons  was  slow,  about  one  shot  per  minute.     The  bullets  were  round, 
weighmg  10  to  the  pound. 

The  Flint  Lock. — This  mechanism  employed  a  flint  fixed  in  the 
hammer  which  on  striking  the  steel-faced  cover  of  the  pan  caused 
sparks  to  ignite  the  powder  overlying  the  vent  or  touchhole.  It  was 
first  used  by  the  French  and  English  in  about  1642  and  descended 
to  us  from  these  nations  during  the  earlier  settlement  of  our  country. 
It  continued  in  use  for  nearly  two  hundred  years,  when  it  was  replaced 
by  the  percussion  cap  gun.  It  is  the  gun  with  which  we  fought  our 
first  three  wars.  At  the  beginning  of  the  last  century,  the  size  of  its 
balls  was  reduced  from  10  to  14  1/2  to  the  pound,  the  charge  of  powder 
was  6  drams,  and  the  bore  of  the  gun  was  .753  inch  diameter. 

Percussion  Cap  Gun. — The  percussion  musket  has  a  hollow  pin 
screwed  into  the  vent  which  insures  direct  communication  with  the 
powder  charge.  A  copper  cap  charged  with  fulminate  powder  is 
placed  over  the  pin  which  on  being  struck  by  the  hammer  detonates 
and  in  turn  ignites  the  explosive  in  the  chamber  of  the  gun.  It  was 
first  used  in  the  English  Army  in  1839  (though  invented  in  1807)  and 
in  our  army  in  1842. 

The  smoothbore  percussion  musket  used  in  the  armies  at  this  time 
had  calibers  ranging  from  .63  to  .75.  It  fired  a  bullet  made  of  soft 
lead  weighing  from  315  to  400  grains  and  the  charge  of  black  powder 
was  irom  75  to  130  grains.  The  projectiles  were  round  with  initial 
velocities  ranging  from  540  to  950  feet  per  second  and  the  effective 
range  rarely  exceeded  350  yards. 

The  imperfect  fit  of  the  ball  in  smoothbore  barrels  permitted  the 
escape  of  so  much  of  the  powder  gases  at  the  time  of  discharge  of 
these  guns,  with  consequent  loss  of  velocity  and  energj^,  that  the  gun 
makers  next  turned  their  attention  to  the  correction  of  this  defect,  and 
in  so  doing  they  evolved  the  hand  rifle,  which  has  since  become  so  valu- 
able to  the  soldier  and  sportsman. 

The  Military  Rifle. — The  earlier  patterns  of  rifled  arms  still  em- 
ployed round  balls  in  barrels  with  straight  grooves.  The  balls  were  a 
trifle  larger  than  the  bore  of  the  gun,  and  they  were  forced  down  to  the 
charge  by  the  use  of  a  ramrod.  Later  the  bullets  were  elongated  to 
allow  more  of  the  surface  of  the  missile  to  come  in  contact  with  the 
barrel.  The  flt  of  the  bah  was  so  tight  that  it  was  necessary  to  employ  a 
hammer  in  addition  to  the  ramrod,  and  hammers  for  the  purpose 
were  added  to  the  equipment.  This  secured  a  better  fit  between  the 
ball  and  barrel,  which  in  turn  added  to  the  energy  and  extended  the 


FIREARMS  5 

range  of  the  ball  by  retaining  it  longer  in  the  barrel  while  the  explosive 
was  generating  gases  in  greater  volume  and  consequently  adding  greater 
pressure.  The  elongated  bullets  fired  from  the  first  rifles  were  apt 
to  tumble  or  lose  their  balance,  and  this  was  overcome  in  a  measure 
by  giving  the  straight  grooves  in  the  barrel  a  slight  twist  or  spiral 
turn  at  the  rate  of  one  complete  turn  in  78  inches.  This  added  sta- 
bility to  the  bullet,  keeping  its  point  forward  in  flight  for  a  greater  time, 
and  it  also  added  to  the  range,  energy  and  accuracy  of  fire.  This 
principle  in  ballistics  and  the  improvement  of  explosives  have  added 
greatly  to  the  effectiveness  of  projectiles. 

To  overcome  the  extreme  difficulty  and  the  loss  of  time  in  loading 
with  the  ramrod  and  hammer,  in  1841  Delvigne,  a  French  army  officer, 
conceived  the  idea  of  making  a  hollow  in  the  base  of  the  bullet  next  to 
the  explosive,  so  that  the  force  of  the  gases  might  press  the  soft  lead  into 
the  metal  grooves  in  the  barrel.  This  prevented  the  escape  of  gas  and 
added  to  the  value  of  the  rifle.  Later,  in  1847,  Captain  Minie  sug- 
gested placing  an  iron  disc  in  the  cup  at  the  base  of  the  bullet.  The 
pressure  of  the  gases  forced  the  iron  disc  forward,  thereby  securing  more 
expansion  of  the  lead.  This  added  greatly  to  the  effectiveness  of 
weapons,  and  although  Captain  Minie's  improvement  related  only  to 
the  projectile,  the  rifles  of  that  day  generally  went  by  the  name  of 
Minie  rifles.  The  iron  device  in  the  bullet,  which  was  later  changed 
to  a  boxwood  plug,  was  employed  in  the  Enfield  rifle  of  the  English 
and  by  other  armies,  whatever  might  be  the  name  of  their  weapons. 

The  following  were  the  principal  features  of  the  Minie  rifle  corre- 
sponding with  the  earlier  makes  of  our  Springfield  rifle: 

MIXIE  RIFLE,  1851  to  1866 

Weight  with  bayonet 10  lb.  8  3/4  oz. 

Diameter  of  bore 702  inch. 

Number  of  grooves 4 

Twist 1  turn  in  78  inches. 

Diameter  of  bullet 690  inch. 

Weight  of  bullet 680  grains. 

Charge  of  powder 150  grains. 

Sight  for  100  to  1000  yards. 

In  1855  we  made  still  further  reductions  in  the  muzzle-loading 
Springfield  rifle,  as  follows: 

CaHber 58  inch. 

Weight  of  bullet 500  grains. 

Charge  of  powder 60  grains. 


6  GUNSHOT   WOUNDS 

The  twist  was  shortened  to  one  turn  in  36  inches,  and  this  was  the  gun 
used  b}^  our  army  until  1866. 

Breechloaders. — The  desire  of  tacticians  to  increase  the  rapidity 
of  fire  on  the  line,  led  to  the  adoption  of  breech-loading  weapons. 
Although  breechloaders  were  known  since  the  reign  of  Henry  VIII, 
they  never  came  into  practical  use  until  the  Germans  used  the  device 
under  the  name  of  the  Needle  Gun  in  the  Austro-Prussian  War  of  1866. 
At  this  time  we  converted  the  Springfield  rifle  of  our  army  to  a  breech- 
loader by  adding  a  breech  lock  which  was  made  to  work  on  a  hinge 
forward,  and  we  reduced  the  caliber  to  .50.  The  device  was  simple; 
slight  pressure  of  the  thumb  of  the  right  hand  opened  the  chamber  for 
the  reception  of  the  metalHc  cartridge  which  had  then  come  into  use. 
Our  troops  were  equipped  with  this  gun  till  1873,  at  which  time  a  new 
model  was  introduced.  The  caliber  was  reduced  to  .45,  the  twist  was 
shortened  to  1  turn  in  22  inches  to  give  the  elongated  bullet  more 
stability,  the  powder  charge  was  retained  at  70  grains,  and  the  weight 
of  the  bullet  was  reduced  to  405  grains.  These  improvements  in- 
creased the  velocity  to  1315  f.s.  with  a  point  blank  range  of  350  yards 
and  a  maximum  effective  range  of  2000  yards.  We  now  had  a  weapon 
which  inexpert  hands  could  be  fired  as  often  as  twenty  shots  per  minute. 
This  was  one  of  the  most  effective  guns  of  its  time.  It  compared  with 
the  German  Mauser,  the  Lee-Speed  of  the  English,  the  Lebel  of  the 
French,  and  the  Spencer,  Sharp  and  Maynard  of  the  sporting  world. 
The  ingenuity  of  man  had  thus  caused  rapid  strides  in  gunmaking 
in  one  generation,  but  those  who  marveled  at  these  marked  changes 
were  scarcely  prepared  for  the  wonderful  improvements  that  were  soon 
to  follow. 

Magazine  Breechloaders  with  Reduced  Caliber. — ^The  rapid  means 
of  locomotion  in  modern  times  have  made  it  possible  to  concentrate 
large  boches  of  troops  at  weak  points,  and  to  ward  off  attacks  by  means 
of  inferior  numbers,  so  that  tacticians  sought  greater  rapidity  of  fire. 
This  led  to  the  introduction  of  the  magazine  rifie,  a  weapon  which 
carries  five  or  more  cartridges  in  a  magazine  that  may  be  placed 
(a)  in  a  tube  under  the  barrel,  (b)  in  a  tube  in  the  stock,  (c)  detachable 
or  fixed  under  the  receiver,  or  (d)  to  one  side  of  the  receiver.  Guns 
with  fixed  magazines  under  the  receivers  are  preferable.  Such  maga- 
zines give  the  piece  better  balance  and  have  been  adopted  by  nearly  all 
the  great  military  nations.  Our  first  magazine  rifle  of  reduced  caliber 
was  adopted  in  1892  under  the  name  of  the  Krag-Jorgensen  rifle,  named 
for  its  inventors,  two  Norwegians.    This  weapon  differed  from  its  prede- 


FIREARMS  / 

cesser,  the  Springfield  breech-loading  rifle,  in  caliber,  and  the  adoption 
of  the  magazine  which  is  placed  below  and  to  the  right  of  the  receiver. 
Its  principal  features  were  as  follows : 

Magazine  fixed,  right  side yes. 

Clip 5  cartridges. 

Cut-off yes. 

Safety  lock yes. 

Weight  without  bayonet 9 .  19  lbs. 

Length  of  barrel 30  inches. 

Caliber,  inches — mm 30-7 .  62 

Number  of  grooves 4 

Depth  of  grooves 004 

Length  of  twist,  turn 1  in  10  inches. 

Direction  of  twist to  right. 

Weight  of  cartridge 435-442  grains. 

Bullet,  material  of  envelope cupro-nickel  steel. 

Bullet,  material  of  core lead  and  tin. 

Bullet,  length  of 1 .26  inches. 

Bullet,  diameter 308  inch. 

Bullet,  weight  of 220  grains. 

Weight  of  charge 35-42  grains. 

Propellent smokeless,  nitrocellulose. 

Initial  velocity 2000  feet  per  second. 

Velocity  of  rotation  of  bullet,  muzzle 2400  turns  per  second. 

Muzzle  energy  in  foot-pounds 1954. 

The  other  features  of  the  gun  are  described  by  Major  George  D. 
Deshon,!  M.  C,  U.  S.  A.,  as  follows: 

''The  magazine  is  below  and  to  the  right  of  the  receiver.  Access 
to  it  is  gained  by  a  gate,  hinged  below,  which  opens  parallel  to  the  bore. 
The  cartridges  are  dropped  sideways  into  the  receiver  through  the 
open  gate,  either  singly  or  in  any  number  up  to  five  at  one  time,  which 
is  the  capacity  of  the  receiver.  Closing  the  gate  presses  a  spring 
on  the  cartridges,  forcing  them  successively  around  under  the  re- 
ceiver and  finally  into  it  from  the  left  side.  A  cartridge  having 
thus  been  placed  in  the  receiver,  the  bolt  handle  is  pushed  forward 
and  then  downward  and  to  the  right,  the  bolt  pushing  the  cartridge 
forward  into  the  chamber,  and  a  lug  on  the  forward  end  of  the  bolt 
engaging  in  a  recess  in  the  bottom  of  the  receiver  firmly  locks  the 
bolt  and  sustains  it  under  the  shock  of  discharge  brought  about 
by  pressure  on  the  trigger.     To  open  the  receiver  the  bolt  handle  is 

^  Association  Military  Surg.  Journal,  Vol.  Ill,  1893. 
2 


8  GUNSHOT   WOUNDS 

turned  upward  and  to  the  left  and  then  pulled  directly  to  the  rear. 
The  first  part  of  the  movement  retracts  the  firing-pin  and  unlocks  the 
bolt.  A  hook  on  the  front  end  of  the  extractor,  which  lies  along  the 
bolt,  next  catches  the  flange  of  the  empty  shell  and  draws  it  back  until 
it  meets  a  lever  in  the  floor  of  the  receiver  by  which  it  is  thrown  out  to 
the  ground.  A  cut-off  is  provided  on  the  left  of  the  receiver  whereby 
the  cartridges  in  the  magazine  may  be  at  any  time  shut  off  and  held  in 
reserve  at  the  will  of  the  soldier.  The  special  advantages  of  this  gun 
are  the  ease  and  simplicity  of  its  bolt  action  and  the  facility  with  which 
it  can  be  at  any  time  loaded,  either  singly  or  as  a  repeater.  It  makes 
no  difference  whether  the  magazine  is  empty  or  partly  full,  whether  the 
bolt  is  forward  or  back,  whether  the  cut-off  is  open  or  closed,  the  gun 
can  still  be  loaded  with  ease  and  always  in  the  same  manner,  thus 
fulfilling  every  need  of  the  hardened  veteran  or  the  impressionable 
recruit." 

This  gun  corresponds  in  effectiveness  for  war  to  the  guns  of  other 
nations  that  were  adopted  at  about  this  time.  In  1903  a  new  arm  was 
perfected,  somewhat  similar  in  its  magazine  and  bolt  to  the  German 
Mauser  Rifle.  This  is  known  as  the  United  States  Rifle,  cal.  .30, 
model  of  1903.     The  weight  of  this,  the  present  service  rifle,  is  about 

9  1/2  pounds;  length  of  barrel,  24.006  inches.  In  1906  radical 
changes  were  made  in  the  ammunition,  as  follows:  The  weight  of 
the  bullet  was  reduced  from  220  to  150  grains.  Instead  of  an 
ogival  head  the  present  bullet  is  pointed,  offering  less  resistance  to 
the  air.  Its  length  has  been  reduced  from  1.26  inches  to  1.08  inches. 
The  powder  charge  has  been  increased  from  about  38  grains  to  about 
48  grains.  The  muzzle  velocity  of  the  new  bullet  has  been  increased 
from  2000  f.s.  to  2700  f.s.,  and  the  velocity  of  rotation  at  the 
muzzle  from  2400  turns  to  3240  turns  per  second.  The  striking 
energy  has  been  increased  from  1954  to  2400  foot-pounds.  The 
extreme  range  has  been  increased  from  4066  to  4891  yards.  Twenty- 
three  aimed  shots  have  been  fired  in  one  minute  with  this  rifle  used 
as  a  single  loader  and  forty  shots  in  the  same  time  from  the  hip  with- 
out aim  using  magazine  fire.  The  ball  penetrates  28.25  inches  of 
thoroughly  seasoned  oak  across  the  grain  at  50  feet,  Fig.  1.  In  the 
modern  rifle^  the  ratio  of  weight  of  bullet  to  weight  of  gun  is  much 
less.  Though  the  velocity  of  the  bullet  has  increased  very  much,  the 
velocity  of  recoil  is  less,  and  the  soldier  is  able  to  withstand  much 
longer  the  shock  of  recoil  on  the  shoulder  with  less  fatigue.     Increased 

1  Ordnance  and  Gunnery,  Lissak,  op.  cit. 


FIREARMS 


9 


muzzle  velocity  has  added  to  the  range  and  accuracy  of  fire.  The  tra- 
jectory is  flatter  and  the  danger  space  has  been  increased  for  all  ranges. 
These  advantages  have  been  attained  with  a  shorter  barrel,  which 
diminishes  the  weight  of  the  gun  and  facilitates  handhng  by  the  soldier. 
Using  the  battle  sight,  the  point  blank  danger  space  is  as  follows: 

Firing  standing 203      yards. 

Firing  kneeling • 636. 6  yards. 

Firing  lying  down 587 . 2  yards. 


Fig.  1. — The  relative  penetration  of  U.  S.  Army  rifle  bullets  in  well-seasoned  oak  across  the 
grain  at  50  feet.  1,  Penetration  of  .45  cal.  Springfield  rifle  bullet,  weight  500  grains,  3.2  inches; 
2,  penetration  of  .30  cal.  Krag-Jorgensen  rifle  bullet,  weight  220  grains,  19.5  inches;  3,  penetration 
of  .30  cal.  new  Spiingfield  rifle  bullet,  weight  150  grains,  28.25  inches. 

The  gun  is  sighted  for  2850  yards.  In  many  respects  this  is  one  of  the 
most  effective  guns  now  used  by  any  army.  The  center  of  gravity  of 
the  bullet  is  placed  well  back,  giving  it  but  little  stability  on  striking 
structures  offering  the  slightest  kind  of  resistance — a  question  which 
will  be  discussed  in  a  later  chapter. 

Carbine. — This  is  a  firearm  carried  by  cavalry.  It  is  very  much  like 
the  military  rifle,  using  the  same  or  lighter  ammunition,  but  with  shorter 
barrel.  In  the  evolution  of  the  military  rifle  nearly  all  mounted  troops 
have  hitherto  been  provided  with  a  carbine,  since  it  is  more  easily  carried 
on  horseback.     In  the  recent  change  in  our  service  to  the  U.  S.  magazine 


10  GUNSHOT   WOUNDS 

rifle,  we  have  so  shortened  the  barrel  of  the  latter  that  it  is  easily  carried 
by  mounted  troopers  and  the  present  weapon  answers  the  purpose  of 
both  branches  of  the  service — cavalry  and  infantry. 

Shotgun. — This  gun  is  so  familiar  to  everyone  that  it  requires  no 
particular  description.  The  more  important  subject  of  missiles  and 
powder  charge  will  be  described  later. 

Revolvers  and  Pistols. — The  familiar  examples  of  revolvers  in  this 
country  are  the  Smith  and  Wesson  and  the  Colt  new  service  double- 
action  revolver.  The  United  States  Army  was  formerly  provided  with  a 
.45  caliber  Colt  revolver,  and  later  the  caliber  was  reduced  to  .38 
inch.  The  latter  is  a  double-action  weapon,^  that  is,  it  can  be  fired  in 
either  of  two  ways,  by  separately  cocking  the  hammer  and  pulling  the 
trigger  or  by  accomplishing  both  operations  with  a  steady  pull  on  the 
trigger.  When  rapidity  of  action  is  required,  the  double-action  mechan- 
ism is  employed,  but  the  fire  is  not  so  accurate.  After  using  this 
weapon  a  number  of  years  its  stopping  power  was  not  considered 
sufficient.  The  United  States  Government,  after  many  trials  of  the 
various  automatic  pistols,  viz.,  the  Savage,  Luger,  and  Colt,  of  calibers 
varying  between  .32  and  .45,  recently  adopted  the  .45  caliber  Colt 
automatic  pistol. 

The  Colt  Automatic  Pistol. — In  this  weapon  there  is  a  movable 
barrel  and  slide,  the  recoil  of  which  ejects  the  empty  shell,  cocks  the 
firing  mechanism,  and  loads  a  new  cartridge  into  the  barrel.  After 
the  first  shot  is  fired  it  is  only  necessary  to  pull  the  trigger  for  each 
succeeding  shot  as  long  as  a  cartridge  remains  in  the  magazine.  The 
magazine  of  the  .  45  caliber  pistol  holds  seven  cartridges,  while  that  of 
the  .  32  and  .  38  calibers  holds  eight  cartridges.  The  magazine  is 
enclosed  in  the  hollow  handle,  is  inserted  from  below,  and  is  held  in 
place  by  a  spring  and  catch.  ^  The  bullet,  composed  of  a  lead  core 
encased  in  a  jacket  of  cupro-nickel,  weighs  230  grains.  The  charge 
is  about  5  grains  smokeless  powder,  and  the  initial  velocity  about  900  f  .s. 
The  automatic  pistol  is  superior  to  the  revolver  as  a  service  arm  for 
the  follomng  reasons : 

1.  Greater  accuracy. 

2.  Less  recoil. 

3.  Rapidity  of  fire. 

4.  Greater  number  of  shots. 

5.  Rapidity  of  loading. 

^  Ordnance  and  Gunnery,  by  Lissak,  op.  cit. 


EXPLOSIVES  11 

Reloading  is  done  in  an  instant  by  inserting  an  extra  magazine. 
The  moral  effect  of  having  this  reserve  ammunition  under  complete 
control  will  be  of  great  value. 

Toy  Pistol. — This  is  really  a  revolver  of  about  .  22  calibers,  employing 
generally  a  blank  cartridge  composed  of  a  brass  shell  and  a  charge  of 
about  6  grains  of  black  powder,  held  in  place  by  a  cardboard  wad.  It 
is  used  in  this  country  bj^  boys  generally  to  celebrate  the  anniversary 
of  our  National  Independence.  Accidents  from  this  weapon  have 
figured  extensively  in  medical  literature  under  the  head  of  toy  pistol 
tetanus  or  4th  of  Juh^  tetanus,  to  which  we  will  refer  later. 

The  Flobert  and  other  target  rifles,  used  in  shooting  galleries,  are 
generally  .22  to  .38  calibers  in  diameter.  They  shoot  round  or 
elongated  bullets  with  velocity  and  energj^  sufficient  to  penetrate  anj^ 
part  of  the  body,  including  the  skull  and  brain. 

3.  EXPLOSIVES 

The  marked  advances  in  the  effectiveness  of  present-day  firearms 
are  largely  due  to  the  use  of  modern  explosives,  which  have  almost 
entirely  superseded  the  use  of  black  gunpowder  as  a  propellent.  The 
latter  still  has  some  valuable  uses,  and  among  explosives  it  is  generally 
the  first  to  be  described. 

Gunpowder  is  an  explosive  substance  formed  by  a  mechanical 
mixture  of 

Saltpeter 75  per  cent. 

Charcoal 15  per  cent. 

Sulphur 10  per  cent. 

100  per  cent. 

Gunpowder  explodes  when  heated  to  572°  F.  In  guns  it  is  exploded 
by  striking  the  primer  in  the  base  of  the  cartridge  which  is  charged 
with  fulminate  powder.  Its  value  as  a  propellent  is  due  to  the  large 
amount  of  gas  which  it  liberates  on  exploding.  The  chemical  results 
of  this  explosion  are:  43  per  cent,  of  gaseous  products  composed  of 
carbonic  acid,  and  nitrogen  with  some  carbonic  oxide  and  aqueous 
vapor.  The  remainder  of  the  charge  is  associated  with  the  gases  in 
the  form  of  finely-divided  solid  substances.  The  volume  of  the  gases 
at  zero  centigrade  and  under  atmospheric  pressure,  liberated  by  the 
explosion,  occupies  280  times  the  bulk  of  the  charge.  The  pressure 
exerted  in  a  closed  vessel  is  said  to  be  as  much  as  5850  atmospheres 


12  GUNSHOT   WOUNDS 

when  the  charge  is  exploded  in  a  space  completely  filled  by  it  (Noble  & 
Abel).  The  temperature  of  the  products  of  explosion  reaches  from 
2000°  to  4000°  C.  In  the  explosion  which  takes  place,  charcoal  fur- 
nishes the  carbon  and  niter  furnishes  the  oxygen  to  burn  the  charcoal 
and  sulphur.  In  addition,  the  latter  adds  to  the  rapidity  of  the 
explosion. 

Modern  Explosives. — These  have  man}^  uses,  but  to  the  surgeon 
they  are  of  special  interest  when  employed  in  war  and  by  evil  doers 
in  attempts  to  destroy  human  life.  The  following  are  the  ones  more 
often  resorted  to  for  the  purposes  mentioned. 

Fulminate  Powder. — -Although  there  are  other  fulminate  powders, 
the  fulminate  of  mercury  is  the  only  one  used  for  military  purposes. 
It  is  used  as  a  detonator  in  exploding  guncotton  and  other  explosives, 
and  also  in  charging  percussion  caps.  It  explodes  instantaneously  and 
with  great  force  by  friction  and  by  percussion.  When  wet  it  may  be 
handled  with  impunity,  and  when  dry  it  burns  quietly  when  kindled 
in  the  open  air.  It  explodes  wihen  heated  to  a  temperature  of  360°  F. 
The  gases  of  the  explosion  are  CO2,  N  and  vapor  of  mercury.  Its 
distinguishing  characters  are  the  large  volume  of  gas  generated  for 
the  bulk  of  the  substance  used,  and  the  rapidity  and  violence  of  the 
explosion.  The  theoretical  pressure  developed  by  the  explosion  of  this 
body  is  28,000  atmospheres.  The  explosive  characteristics  of  the  sub- 
stance were  displayed  in  the  Orsini  attempt  to  assassinate  the  French 
Emperor  in  1858,  when  three  bombs  were  exploded,  each  containing  4 
ounces  of  mercuric  fulminate:  511  wounds  were  inflicted  on  156  persons. 

Smokeless  Powders. — The  name  of  these  explosives  comes  from 
the  fact  that  they  emit  very  little  smoke  on  exploding  as  compared 
to  black  gunpowder.  Two  classes  of  smokeless  powders  are  now  or 
have  been  recently  in  use  in  our  service :  Nitroglycerin  powder,  used 
for  the  hand  weapons,  and  nitrocellulose  powder,  now  used  for  both 
small  arms  and  cannon.  They  are  both  made  from  guncotton,  but 
the  nitroglycerin  powder  has  from  10  per  cent  to  30  per  cent  of 
nitroglycerin.  The  temperature  of  the  explosion  of  the  latter  material 
is  higher,  and  as  the  erosion  of  the  metal  of  the  bore  increases  with  the 
temperature,  the  life  of  the  large  costly  guns  is  very  much  shortened 
by  the  use  of  the  nitroglycerin  powder.  For  this  reason  nitrocellulose 
powder  is  generally  preferred  for  use  in  cannon.  Another  objection  to 
the  use  of  nitroglycerin  powder  for  large  guns,  was  its  greater  liability 
of  spontaneous  ignition  when  deteriorating  in  unfavorable  storage 
conditions.     In    the    hand    weapons,    the    nitroglycerin    powder    is 


EXPLOSIVES  13 

hermetically  sealed  in  the  cartridge,  and  its  keeping  qualities  and 
stability  are  preserved,  and  for  these  reasons  it  can  be  used  with  safety 
in  small  arms. 

One  of  the  typical  nitroglycerin  powders  used  abroad  is  composed 
of— 

Insoluble  nitrocellulose 67 .  25  per  cent. 

Nitroglycerin 30 .  00  per  cent. 

Metallic  salts ,. 2 .  75  per  cent. 

100.00  per  cent. 

Forty  pounds  of  acetone  is  the  solvent  for  a  hundred  pounds  of  this 
mixture.  The  jelly-like  paste,  after  various  treatments  in  shaping  and 
drying,  is  cut  into  bead-like  grains,  perforated  and  graphited. 

Cordite. — This  is  an  English  nitroglycerin  powder,  composed  as 
follows : 

Nitroglycerin 30  per  cent. 

Guncotton 65  per  cent. 

Vaseline 5  per  cent. 

100  per  cent. 

The  vaseline  is  added  to  render  the  powder  waterproof  and  to  improve 
its  keeping  qualities. 

Nitrocellulose  Powder. — This  is  the  powder  used  in  cannon.  It 
is  composed  of  guncotton  containing  12.65  per  cent  nitrogen  dissolved 
in  two  parts  of  ether  to  one  of  alcohol.  The  powder  issues  from  the 
press  as  a  colloid,  and  it  is  cut  into  grains  of  suitable  size  and  prepared 
as  stated  under  nitroglycerin  powder,  except  that  cannon  powder  is 
not  graphited  as  a  rule.  In  our  service  the  powder  is  formed  into 
cylindrical  grains  with  seven  longitudinal  perforations  giving  a  uniform 
thickness  of  web.  The  powder  is  brown  in  appearance  and  the  grain 
differs  in  size  with  the  caliber  of  the  gun. 

In  other  services  cannon  powders  are  made  into  grains  of  various 
shapeS;  such  as  cubes,  solid  and  tubular  rods,  circular  cross-section, 
flat  strips,  and  rolled  sheets. 

The  advantages  of  smokeless  powder  lie  in  the  fact  that,  unlike 
black  powder,  the  smokeless  powder  is  almost  entirely  converted  into 
gas;  and  with  smaller  charges  it  is  possible  to  give  equal  or  higher 
velocity  to  the  projectile;  it  leaves  no  residue  in  the  bore.  The  theo- 
retical pressures  when  exploded  in  its  own  volume,  exerted  by  guncot- 
ton, is  24,000,  and  as  much  as  25,000  atmospheres  by  nitroglycerin — 


14  GUNSHOT   WOUNDS 

more  than  four  times  greater  than  that  developed  by  the  explosion  of 
gunpowder. 

There  are  other  explosives  of  interest  to  the  surgeon.  They  are 
the  so-called  picric  acid  compounds,  known  under  the  familiar  names 
of  melenite,  emmensite,  liddite,  etc.  They  emit  fumes  on  exploding 
which  irritate  the  conjunctiva  and  air  passages. 

The  Sprengel  explosives,  known  under  the  names  of  bellite,  hellofite, 
and  roburite,  are  high  explosives  which  are  harmless  when  the  compo- 
nent parts  are  kept  separated;  when  mixed  they  detonate  with  great 
violence. 

Compressed  Atmospheric  Air. — Compressed  air  is  used  as  a  pro- 
pellent in  air  guns  in  shooting  galleries  principally.  Compressed  air 
has  no  application  as  an  explosive  in  military  practice  because  of  the 
limited  range  which  it  confers  on  the  projectile. 

4.  PROJECTILES 

The  term  projectile  is  applied  to  missiles  from  firearms  in  general. 
The  term  as  used  in  these  pages  is  sjmonymous  with  the  term  bullet 
when  it  refers  to  projectiles  from  hand  weapons.  Missiles  propelled 
by  the  bursting  charge  of  grenades,  bombs,  and  mines  are  also  referred 
to  as  projectiles. 

Projectiles  may  be  divided  into  three  classes: 

1.  Projectiles  from  hand  weapons. 

2.  Projectiles  from  artillery. 

3.  Projectiles  from  grenades,  bombs,  and  mines. 
Projectiles   from    Hand   Weapons. — The   hand  weapons  include 

rifles,  pistols,  and  revolvers,  shotguns,  and  air  guns.  The  present- 
day  projectiles  from  hand  weapons,  pistols,  and  revolvers  are  con- 
veniently classed  as  follows:  (a)  penetrating  bullets,  (b)  setting-up 
bullets,  (c)  disintegrating  bullets,  (d)  explosive  bullets. 

(a)  Penetrating  Bullet. — This  is  a  bullet  made  up  of  a  core  of  hard 
lead  enclosed  in  a  m.antle  of  cupro-nickel  steel.  It  is  the  bullet  of  the 
reduced  caliber  military  rifle  the  world  over,  and  it  is  also  employed  in 
the  automatic  pistols  that  are  now  coming  into  such  favor.  This 
bullet  rarely  disintegrates  in  the  human  body,  and  it  seldom  deforms. 
When  making  a  regular  impact  it  generally  penetrates  point  on. 

(b)  Setting-up  Bullet. — This  bullet  is  made  of  soft  lead  in  order  to 
promote  deformation  on  impact  against  bony  structures.  This  was 
the  bullet  of  olden  times  before  the  days  of  rifle  weapons  and  until 
the  lead  was  hardened  with  antimony. 


PROJECTILES 


15 


(c)  Disintegrating  or  Dum-dimi  Bullets. — These  bullets  are  also 
called  metal  patch  bullets  in  the  trade.  They  are  mantled  projectiles 
except  at  the  tip  end,  where  the  lead  core  is  fully  exposed.  Such  a 
bullet  readily  disintegrates  on  impact  against  resistant  structures  like 
bone.  The  core  and  the  steel  case  break  up  into  many  fragments,  each 
acting  as  a  projectile. 

(d)  Ex-plosive  Bullets. — These  projectiles  are  hollow  lead  bullets  in 
which  an  explosive  is  placed.  A  cap  is  fixed  in  the  nose  of  the  bullet 
to  promote  explosion  on  impact.  The  effects  of  such  a  bullet  do  not 
differ  from  those  of  a  dum-dum  projectile.  Their  use  is  proscribed  by 
the  comitj"  of  nations. 

In  addition  to  the  foregoing  projectiles,  armies  generally  have  blank 
ammunition  in  which  the  bullet  is  replaced  by  a  wad  of  cardboard, 
or  paper.     This  blank  ammunition  is  used  for  ceremonies  and  drills. 


CAL.    .4-5 

SPRINGFIELD  F.IFLE 

BULLET 


CAL.    .30 

MODEL  OF  1903, 

BULLET 


CAL.    .30 

MODEL  OF  1906, 

BULLET 
A 

/\ 

CAL.    .33 

CAL.    .45 

/             \ 

REVOLVER 

AUT.  PISTOL 

BULLET 

BULLET 

LENGTH-INCH 

1.31 

1.26 

1.08 

DIAMETER-INCH 

.456 

.303 

.308 

WEIGHT-GRAINS 

500 

220 

150 

Fig.  2. — 3  and  5  represent  the  shape  and  size  of  the  rifle  and  pistol  bullets  in  present  use  by  the 
United  States  Army.     1,  2  and  4  represent  the  rifle  and  revolver  bullets  recently  discarded. 


Projectiles  from  Pistols  and  Revolvers. — These  correspond  very 
nearly  in  caliber  and  composition  to  the  projectiles  of  the  military 
rifle.  They  usually  weigh  less  and  they  are  shorter.  For  special 
reference  to  their  shape  and  composition  see  Fig.  2,  also  table  No.  3., 
pages  70  and  71. 

Shotgun  projectiles  vary  from  fine  lead  pellets,  2020  to  the  troy 
ounce,  to  buckshot,  which  are  .31  inch  in  diameter.  The  smallest 
pellets  weigh  a  fraction  of  a  grain  and  the  buckshot  weigh  38  grains. 
Shotgun  projectiles  are  all  round,  and  they  are  composed  of  hard  lead. 
The  number  of  missiles  to  each  cartridge  depends  on  the  bore  of  the 
gun  and  the  size  of  the  pellets. 


16 


GUNSHOT   WOUNDS 


The  projectile  from  the  toy  pistol  is  the  entire  charge,  which  is  made 
up  of  the  cardboard  wad  and  about  6  grains  of  black  powder. 

The  projectile  from  the  air  gun  and  Flobert  rifle  is  an  elongated  or 
a  .22  BB  round  shot  made  of  lead  hardened  with  antimony. 

Projectiles  from  Artillery. — These  are  classed  as  shot,  shell,  and 
case  shot. 

Solid  shot  is  no  longer  used  in  modern  cannons.  The  projectile 
called  a  shot  is  now  hollow  with  thick  walls.  It  is  principally  used  to 
perforate  armor  and  carries  a  small  bursting  charge. 

Shell.^ — The  shell  is  a  hollow  projectile  with  thin- 
ner walls  than  the  preceding.  It  is  also  provided 
with  a  large  bursting  charge.  It  is  used  to  destroy 
persons  or  material  (Figs.  3  and  4). 

Pom-pom  shell  is  another  kind  of  shell.  It  derives 
its  name  from  the  report  of  its  discharge.  It  is  fired 
from  the  one-pounder  Vickers-Maxim  automatic  gun. 
It  is  1 .  457  inches  in  diameter,  3  3/4  inches  in  length, 
and  weighs  16  ounces.  It  explodes  by  percussion. 
This  shell  is  used  to  kill  and  wound  the  enemy,  hence 
like  the  cannon  shell  it  breaks  into  many  fragments. 
Case  Shot. — This  consists  of  a  number  of  shot 
held  together  in  a  metal  case,  which  may  be  ruptured 
by  the  shock  of  discharge,  or  by  a  bursting  charge. 
The  term  canister  or  grape  shot  is  applied  to  the  for- 
mer and  the  term  shrapnel  is  applied  to  the  latter. 
The  modern  projectiles  of  the  artillery  arm  are  all 
cylindrical  with  an  ogival  head,  except  the  canister, 
which  has  a  flat  head. 

Canister. — In  this  projectile  the  metallic  envelope 
is  filled  with  small  balls  which  are  liberated  by  the 
shock  of  discharge.  Canisters  are  used  at  short  range 
when  the  guns  of  a  battery  are  in  danger  of  capture. 
Each  3-inch  canister  contains  244  iron  balls,  5/8  of  an  inch  in  diame- 
ter, weighing  30  to  the  pound,  placed  in  a  receptacle  the  shape  of  an 
elongated  can.  The  canister  has  been  entirely  superseded  by  the 
modern  shrapnel. 

The  Shrapnel. — ^The  shrapnel  is  of  special  interest  to  surgeons 
because  of  its  increasing  importance  in  augmenting  the  casualty  list 
of  battles  in  modern  wars.  The  shrapnel  is  a  projectile  which  carries 
a  number  of  bullets  at  a  distance  from  the  gun  where  they  are  dis- 


FiG.  3.— The  3- 
incli  common  steel 
shell  used  in  U,  S. 
Army. 


PROJECTILES 


17 


18 


GUNSHOT    WOUNDS 


charged  with  added  energy  over  a  wide  area  from  the  point  of  burst- 
ing. It  has  become  the  principal  projectile  of  all  modern  field  artil- 
lery. It  forms  80  per  cent  of  the  ammunition  supply  of  the  field  guns.^ 
It  is  used  against  troops  in  masses  and  material  as  well.  It  is  used, 
also,  in  mountain  and  siege  artillery,  and  in  the  smaller  guns  of  sea  coast 
fortifications  to  repel  land  attacks.  (See  Fig.  5.)  In  this  shrapnel 
the  case  is  a  steel  tube  with  a  solid  base.  The  weight 
of  the  3-inch  field-gun  shrapnel  complete  is  15  pounds, 
length  10  inches,  muzzle  velocity  1700  f.s.  The  burst- 
ing charge  is  composed  of  2  3/4  ounces  black  powder 
placed  in  a  chamber  at  the  base.  There  is  a  stop- 
per of  guncotton  in  the  central  tube  to  hold  the 
powder  in  place  and  to  assist  in  the  explosion.  There 
are  252  round  balls,  flattened  on  six  faces,  of  .  50  inch 
caliber,  composed  of  lead  hardened  with  antimony. 
The  balls  are  surrounded  by  a  smoke-producing  matrix, 
which  is  used  to  locate  the  point  of  bursting.  This 
shrapnel  is  said  to  be  a  man-killer  at  6500  yards. 
At  the  latter  distance  the  shrapnel  has  a  remaining 
velocity  of  565  f.s.  On  bursting,  an  additional  velo- 
city of  300  f.s.  is  conferred  on  the  lead  bullets,  making 
altogether  a  remaining  velocity  of  865  f.s.  at  6500 
yards.  The  fuse  can  be  set  to  cause  the  projectile  to 
explode  at  any  one-fifth  of  a  second  in  its  flight. 

The  older  shrapnels  were  made  up  of  a  cast-iron 
case  and  diaphragm  that  separated  the  balls.  The 
case  was  constructed  to  invite  rupture  into  a  number 
of  fragments.  The  bursting  charge  was  placed  gener- 
ally in  the  head  of  the  projectile.  This  old-time  shrapnel  broke  into 
a  greater  number  of  fragments,  but  they  were  not  always  possessed  with 
sufficient  energy  to  inflict  severe  injury.  The  present  shrapnel  has 
the  bursting  charge  located  in  its  base.  It  is  made  of  a  stout  case, 
which  remains  intact  at  the  time  of  bursting,  except  for  the  blowing 
out  of  the  head. 

The  following  table  gives  the  area  of  dispersion  and  other 
important  data  on  shell  and  shrapnel  used  in  guns  of  different 
calibers. 

1  Ordnance  and  Gunnery,  by  Ormond  M.  Lissak,  Lt.  Col.,  Ordnance  Depart- 
ment, U.  S.  A. 


Fig.  5. — C  o  m- 
mon  shrapnel  used 
in  U.  S.  Army. 


PROJECTILES 
AREA  OF  DISPERSION 


19 


Shrapnel 


Length, 
yards 


Width, 

yards 


At  a  range  less  than 
3000  yards. 


Field  gun 
Mountain 
howitzer 


400 
300 


150 
100 


At  a  range  over  3000 
yards. 


Field  gun 
Mountain 
howitzer 


300 

200 


125 
75 


Shell 


Length,!  Width, 
yards    '    yards 


300 
250 


250 
150 


100 
75 


75 
75 


Area  of  dispersion  about 
100  yards  wide  and  150 
yards  long,  very  effect- 
ive within  a  central 
zone  of  about  30  yards 
wide  and  20  yards  long. 


FIELD  ARTILLERY 


Extreme 
range, 
yards 

Shrapnel 

Shell 

Gun 

Weight 

^T        ,         Size     and 
No.  of              •   .  ,     c 
,     ,,  ^           weight  of 
bullets           u    11  ^ 
bullets 

Weight 

Approximate  No. 
of  eflective  frag- 
ments 

3-inch    field  gun    and          Gun 

mountain  howitzer.           6500            15  lb. 
Howitzer 
5600 

252 

.5  in. 
167  grains 

15  lb. 

600 

3.8-inch       gun       and          Gun 
howitzer.                       ;        7300 

Howitzer 
!        6200 

30  lb. 

340 

.54  in. 
230  grains 

30  1b. 

800 

4.7-inch  gun  and 
howitzer 

Gun 

8000 

Howitzer 

6640 

60  lb. 

711 

.54  in. 
230  grains 

60  1b. 

1000 

6-inch  howitzer                       6704           120  lb. 

1074 

.6  in.            120  lb. 
306 . 4  grains 

1500 

Grenades,  Bombs,  Mines,  and  Torpedoes. — Hand  and  rifle  grenades 
have  recently  come  into  prominence  as  projectiles.  Hand  grenades 
were  among  the  earliest  forms  of  explosive  projectiles  used  in  war. 
Trained  soldiers,  called  grenadiers,  threw  grenades  by  hand  in  repelling 
attacks,  etc.  The  earlier  grenades  were  composed  of  a  hollow  ball  or 
cylinder  of  metal,  glass  or  paper,  2  or  3  inches  in  diameter,   filled 


20 


GUNSHOT   WOUNDS 


with  an  explosive  which  was  exploded  by  a  fuse  upon  falhng  amon^ 
the  enemy.  Their  employment  was  aban- 
doned in  the  latter  part  of  the  seven- 
teenth century.  Dynamite  grenades  were 
first  used  at  the  siege  of  Mafeking  by  the 
besieged.  The  modern  grenade  came  into 
special  prominence  in  the  Russo-Japanese 
war  as  a  result,  no  doubt,  of  the  great  ad- 
vances in  the  apphcation  of  high  explosives. 
The  hand  grenade  of  the  Japanese  is  sus- 
pended from  the  cartridge  belt,  Fig.  6. 
It  consists  of  two  parts,  the  body  and  the 
handle.     The  body  is  a  tin  cyhnder,  4  1/2 


Fig.   6. — Dummy  of   a  Japanese  hand  grenade. 


Fir. 


PROJECTILES 


21 


cm.  in  diameter  by  6  cm.  in  length,  filled  with  shimose  powder  and 
provided  with  a  time  fuse.  The  cylinder  is  also  provided  with  a  per- 
cussion cap  at  the  far  end.     To  ensure  the  grenade  falling  cap-end 


Fig.  S. 


first,  it  is  piloted  by  a  kite-tail  arrangement  placed  at  the  rear  end  of 
the  handle,  and  a  weighted  lead  ring  is  fixed  on  the  base  at  the  opposite 
end  of  the  grenade,  which  is  provided  with  the  cap.     The  grenade 


5  ^  J^^ ml'-X.^ I 


Fig.  9. 


breaks  into   many  fragments,  and  in  addition  it  emits  a  gas  which 
causes  painful  irritation  to  the  conjunctiva  and  air  passages. 

"In  the  latter  part  of  the  war  at  Port  Arthur  the  Japanese  abandoned 
the  hand  grenade  for  a  can  filled  with  a  high  explosive  which  was  placed 


22  GUNSHOT   WOUNDS 

in  a  small  mortar.  Some  of  the  latter  were  made  of  wood,  in  which  a 
small  charge  of  powder  gently  lifted  the  can,  which  was  usually  filled 
wdth  sliimose,  from  200  to  400  yards,  where  a  frightful  explosion  would 
occur"  (Lynch). 

In  our  service  we  employ  a  grenade  (Fig.  7)  which  corresponds  very 
nearly  to  the  Japanese  hand  grenade,  except  that  the  body  is  made 
of  steel  instead  of  tin.  There  is  also  a  grenade  fired  from  the  rifle,  as 
shown  in  Fig.  8.  This  is  a  great  advantage,  as  the  .body  of  the  solcUer 
need  not  be  exposed  in  propelling  the  grenade,  as  in  the  case  of  the  hand 
grenade  of  the  Japanese  a^m3^  Fig.  9  shows  the  fragmentation  of  the 
U.  S.  grenade. 

Hand  Bombs. — These  projectiles  were  extensively  used  by  both 
combatants  in  the  Russo-Japanese  war  at  Port  Arthur.  The  bomb 
of  the  Japanese  weighed  about  14  pounds.  It  was  composed  of  pyrox- 
ylin and  melenite  placed  in  linen  bags  provided  with  a  fuse  of  fulminate 
of  mercurj^  The  bags  were  suspended  from  the  soldier's  neck,  and 
they  were  thrown  among  the  enemy  at  opportune  moments.  The 
Russians  emplo3^ed  a  hand  bomb,  composed  of  600  to  1400  grams  of 
different  kinds  of  explosives  loaded  into  the  copper  case  of  their  empty 
3-inch  shells,  provided  with  a  fuse.  The  destructive  effects  of  such  pro- 
jectiles are  similar  to  those  of  guncotton,  viz.,  the  violent  displacement 
of  air  as  detonation  takes  place. 

Mines  and  Torpedoes. — Mines  and  torpedoes  figure  extensively  in 
naval  coml^at  and  in  harbor  defenses.  The  land  forces  are  specially 
interested  in  terrestrial  mines  which,  like  submarine  mines,  torpedoes, 
etc.,  are  made  by  confining  a  charge  of  explosive  in  a  case  which  is 
exploded  by  clock-work,  by  contact,  or  by  an  electric  spark  under  the 
control  of  an  indi\adual  at  a  central  point.  The  terrestrial  mines  of 
the  combatants  in  the  Russo-Japanese  War  were  composed  of  wooden  or 
metallic  cases  holding  about  12  pounds  of  pyroxylin.  The  cases  were 
buried  3  feet  underground  about  200  yards  from  the  line  of  defense, 
disposed  in  two  rows  40  to  50  yards  apart,  the  mines  in  each  row  being 
disposed  at  intervals  of  10  to  12  yards.  The  projectiles  set  in  motion 
with  each  explosion  were  made  up  of  dirt,  gravel,  pieces  of  the 
casing,  and  the  rapid]}"  displaced  air  at  or  near  the  locality  of  the 
explosion. 

Projectiles  from  Gatling  and  automatic  machine  guns  are  the  same 
as  used  in  the  hand  rifle  of  foot  troops  described  under  the  term 
penetrating  bullets  in  the  beginning  of  this  chapter,  and  which  will  be 
referred  to  extensively  in  succeeding  chapters. 


BALLISTICS  23 

5.  BALLISTICS 

I.  Motions  of  Projectiles. 

(A)  The  motion  of  translation. 

1.  The  force  of  explosion. 

2.  Air  resistance. 

3.  The  force  of  gravitj^ 

4.  Combined  effect  of  forces. 

(B)  The  motion  of  rotation. 

II.  The  Trajectory. 

(a)  The  danger  space. 

(b)  Factors  that  affect  the  trajectory.  * 

(c)  Sectional  density  and  form. 

1.  THE  MOTIONS  OF  PROJECTILES 

Projectiles  of  early  form  fired  from  smoothbore  guns,  being  spher- 
ical, had  but  one  motion  imparted  to  them,  that  of  translation.  To 
oblong  proj  ectiles,  in  addition  to  the  motion  of  translation,  is  given  a 
motion  of  rotation  to  steady  them  in  their  flight.  Attention  will  be 
given  first  only  to  the  motion  of  translation. 

(A)  The  Motion  of  Translation. — -A  projectile  fired  from  a  gun  is 
acted  upon  by  three  forces:  the  force  of  discharge,  or  of  explosion, 
which  sets  the  projectile  in  motion;  the  air  resistance,  which  opposes  the 
motion  of  the  projectile  and  which  is  therefore  a  retarding  force;  and 
the  force  of  gravity,  which  tends  to  deflect  the  projectile  toward  the 
center  of  the  earth.  Brief  consideration  will  be  given  to  these  forces, 
the  effect  of  each  separate^  on  the  projectile,  and  the  resultant  of 
their  combined  effects. 

(1)  The  Force  of  Explosion. — The  force  of  discharge  is  due  to  the 
explosion  of  the  powder  with  which  the  gun  is  charged.  This  explosion 
is  a  chemical  action  between  the  constituent  elements,  which  liberates 
gas  and  generates  heat.  A  certain  amount  of  powder  will,  when  sub- 
jected to  this  chemical  action,  liberate  a  certain  volume  of  gas,  generate 
a  certain  amount  of  heat,  and  sometimes  form  a  certain  amount  of 
solid  matter  or  residue.  Modern  smokeless  powder  leaves  practically 
no  residue.  The  gas,  being  at  a  high  temperature  and  confined  to  a 
small  space,  will  exert  a  high  pressure  on  the  walls  of  the  gun  and  upon 
the  base  of  the  projectile.  The  walls  and  the  breech  of  a  gun  are  de- 
signed to  withstand  the  powder  pressure,  so  that  the  expansive  force  of 
the  powder  gas  can  be  expended  only  in  driving  the  projectile  from  the 
gun.     The  projectile,  therefore,  leaves  the  bore  of  the  gun  with  a 

3 


24  GUNSHOT   WOUNDS 

certain  muzzle  velocity,  and  for  similar  guns,  similar  projectiles,  and 
equal  powder  charges,  this  velocity  will  be  the  same. 

Slightly  beyond  the  muzzle  of  the  gun  the  powder  gases  cease  to 
act  on  the  projectile,  and  it  moves  forward  with  a  certain  velocity, 
which  according  to  the  laws  of  physics,  would  remain  constant  if 
there  were  no  air  resistance,  or  retardation  due  to  any  other  medium, 
and  no  force  of  gravity;  the  projectile  would  then  continue  to  travel 
indefinitely  into  space  at  a  constant  velocity. 

(2)  Air  Resistance. — The  effect  of  air  resistance  on  the  velocity  of 
a  projectile  has  been  the  subject  of  diligent  research.  From  the  time 
of  Benjamin  Robins  and  his  experiments  with  the  ballistic  pendulum 
and  the  whirling  machine,  in  the  year  1742,  to  the  experiments  of  Bash- 
forth  and  Mayevski,  in  the  latter  part  of  the  nineteenth  century,  with 
modern  projectiles  at  high  velocities,  and  to  our  own  test  and  proof  fir- 
ings at  the  ordnance  establishments,  the  science  of  exterior  ballistics 
has  been  developed  and  improved  to  such  a  degree  that  the  path  of  a 
projectile  can  be  calculated  with  remarkable  accuracy.  From  these 
experiments  expressions  have  been  deduced  for  the  retardation  due  to 
the  air  in  terms  of  constants  depending  upon  the  form  of  the  project- 
ile, of  constants  depending  upon  the  velocity  of  the  projectile,  of  fac- 
tors of  the  velocity,  and  of  factors  depenchng  upon  the  atmospheric 
condition.  The  retardation  of  the  sharp-pointed  bullet  used  in  the 
United  States  rifle,  caliber  .30,  model  of  1903,  or  the  rate  at  which  its 
velocity  is  decreased,  is  calculated  to  be  about  2100  feet  per  second 
while  the  bullet  has  a  velocity  of  from  2600  to  2700  feet  per  second, 
about  850  feet  per  second  while  it  has  a  velocity  of  from  1370  to  1800 
feet  per  second,  and  about  18  feet  per  second  while  it  has  a  velocity 
below  790  feet  per  second.  These  figures  show  that  at  the  higher 
velocities  air  resistance  is  a  factor  of  great  importance. 

It  is  seen,  then,  that  a  large  portion  of  a  projectile's  energy 
is  expended  in  overcoming  the  air  resistance,  that  the  resistance  is 
greatest  during  the  period  at  which  it  maintains  a  high  velocity,  and 
that  were  there  no  force  of  gravity  to  draw  the  projectile  to  earth  the 
projectile  would  travel  in  a  straight  line  but  with  a  variably  decreasing 
velocity  until  finally  it  came  to  rest  at  an  infinite  distance  from  the  gun. 
(3)  The  Force  of  Gravity. — Gravity  is  the  force  that  attracts  all 
bodies  toward  the  center  of  the  earth.  It  is  a  continuous  force,  and 
therefore  an  accelerating  force.  That  is,  if  it  acts  on  a  free  body  one 
second  it  will  give  that  body  a  certain  acceleration,  and  should  it  cease 
to  act  after  the  first  second  the  bodv  would  continue  to  fall  at  a  constant 


BALLISTICS 


25 


velocity,  neglecting  air  resistance;  but  the  force  continues  to  act 
through  the  second  second  and  every  following  second,  giving  the 
body  the  same  acceleration  each  second.  The  acceleration  due  to 
gravity  is  32.16  feet  per  second;  this  value  varying  slightly  with  the 
latitude  and  longitude  of  the  place.  In  vacuo,  then,  a  body  falling 
would  have  a  velocity  of  32.16  feet  per  second  at  the  end  of  the  first 
second,  a  velocity  of  64.32  feet  per  second  at  the  end  of  the  second  sec- 
ond, of  96.48  feet  per  second  at  the  end  of  the  third  second,  and  so  on, 
or  the  velocity  v  at  any  time  would  be  equal  to  gt,  the  product  of 
the  acceleration  and  time. 

The   height   h   through    which  a  ho&y  would  fall  at  a  constant 
velocity  equals  the  product  of  time  and  velocity  vt.     But  a  falling 


Fig.   10. 


body  has  a  variable  velocity,  and  it  becomes  necessary  to  find  an 
average  velocity.  For  a  body  starting  from  rest  and  falling  at  a  con- 
stant acceleration,  the  average  velocity  is  one-half  its  final  velocity. 
Since  we  have  seen  that  the  final  velocity  is  equal  to  gt,  the  height 
of  fall,  h,  equals  1/2  gt~,  one-half  the  product  of  the  acceleration  and 
the  square  of  the  time.  Projectiles,  therefore,  are  given  an  accelera- 
tion downward  the  instant  they  leave  the  muzzle  of  the  gun.  If  the 
axis  of  a  gun  fired  is  horizontal,  the  projectile  will  have  fallen  16.08 
feet  below  this  axis  at  the  end  of  the  first  second,  64.32  feet  at  the  end 
of  the  second  second,  and  144.72  feet  at  the  end  of  the  third  second, 
and  so  on. 

(4)   The  Comhined  Effect  of  the  Forces. — Referring  to  Fig.  10,  A,  B, 
C,  and  D  mark  the  distances  a  fired  projectile  will  have  traveled  from 


26  GUNSHOT   WOUNDS 

gun  0  at  the  end  of  the  first,  second,  third,  and  fourth  seconds,  respec- 
tively, neglecting  air  resistance  and  gravity.  Under  that  assumption 
we  have  seen  that  the  projectile  would  travel  in  a  straight  line  at  a 
constant  velocitj^;  therefore  the  intervals  between  these  points  are 
equal.  But,  due  to  air  resistance,  the  velocity  of  the  projectile  is 
being  constantlj''  decreased,  so  that  actually  the  projectile  travels  only 
to  A'  during  the  first  second  and  only  reaches  points  B',  C ,  and  D' 
at  the  end  of  the  second,  third,  and  fourth  seconds. 

If,  on  the  other  hand,  the  projectile  were  dropped  from  the  muzzle 
of  the  gun  (Fig.  10),  it  would  fall  the  distance  Oa  during  the  first 
second,  to  h  during  the  second  second,  and  to  c  and  d  during  the  third 
and  fourth  seconds,  neglecting  air  resistance.  But  clue  to  air  resistance, 
it  falls  only  to  the  points  a',  h',  c',  and  d'  during  those  four  seconds. 

Combining  these  two  motions,  the  vertical  and  horizontal,  to  ob- 
tain the  actual  resulting  motion  (Fig.  10),  we  find  that  at  the  end  of 
the  first  second  the  projectile  will  have  traveled  the  horizontal  distance 
OA',  but  it  will  also  have  fallen  the  vertical  distance  Oa',  so  that 
actually  it  will  have  reached  the  point  A".  And  similarlj^  at  the  end 
of  the  following  seconds,  it  will  have  reached  the  points  B",  C",  andD", 
and  so  on.  Since  the  air  resistance  tends  to  bring  the  projectile  to  rest, 
and  gravity  constantly  increases  its  velocitj^  of  fall,  it  is  easily  seen 
that,  given  the  space,  the  projectile  would  tend  to  assume  a  vertical 
direction  of  motion. 

(B)  The  Motion  of  Rotation. — To  keep  the  oblong  projectile  in 
its  direction  of  travel,  it  is  given  a  motion  of  rotation  about  its  longer 


Fig.   11. 


axis.  This  rotary  motion  prevents  the  projectile  from  tipping  when 
the  resultant  air  resistance  becomes  oblique  to  the  axis  of  the  project- 
ile. Fig.  11  shows  a  projectile  fired  horizontally.  It  has  a  tendenc}'' 
to  keep  its  axis  parallel  to  the  axis  of  the  gun,  and  so  long  as  the  pro- 
jectile travels  in  a  line  with  its  axis,  the  resultant  air  resistance  coin- 
cides "^dth  its  axis.  But  the  projectile  takes  a  course  downward;  so 
that  the  resultant  air  resistance  will  make  an  angle  with  the  axis  and 
passing  over  its  center  of  gravity  will  tend  to  tip  the  projectile. 


BALLISTICS 


27 


This  rotation  is  caused  bj^  spiral  grooves,  called  rifling,  cut  in  the 
bore  of  the  gun.  As  the  projectile  passes  through  the  bore  it  engages 
with  these  grooves  and  is  turned  by  them.  The  velocity  of  rotation 
of  a  projectile  depends  upon  its  linear  velocity  and  upon  the  twist  of 
the  rifling.  In  the  present  .  30  caliber  service  rifle  the  twist  is  one  turn 
in  10  inches. 


But  though  the  rotation  prevents  the  projectile  from  tipping,  it 
causes  it  to  deviate  from  the  vertical  plane  of  fire.  This  deviation  is 
called  drift.  There  seems  to  be  a  difference  of  opinion  as  to  the  cause 
of  drift,  whether  it  is  a  gyratory  effect,  or  whether  the  projectile  tends 


Fig.  13. 

to  roll  on  the  more  dense  air  beneath  it;  suffice  it  to  know  that  it  is 
due  to  air  resistance.  The  drift  of  a  gun  is  in  the  direction  of  its  rifling, 
a  right-handed  tT^dst  causing  a  drift  to  the  right,  and  vice  versa. 

Figure  12  shows  the  drift  curve,  up  to  2000  yards,  of  the  present 
caliber  .30  service  rifle.  AC  is  the  path  of  deviation  of  the  projectile 
from  the  vertical  plane  AB. 


28 


GUNSHOT  WOUNDS 


II.  THE  TRAJECTORY 


The  curve  described  by  the  center  of  gravity  of  a  projectile  during 
its  passage  through  the  air  is  called  the  trajectory.  In  vacuo  a  trajec- 
tory would  be  a  parabola,  but  the  curve  is  greatly  deformed  from  that 
of  a  parabola  by  the  air  resistance.  Fig.  13  shows  the  trajectories  of 
the  caliber  .45  Springfield  rifle,  the  Krag-Jorgensen  rifle,  and  the 
present  cahber  .30  service  rifle  at  a  range  of  1000  yards. 

(a)  The  Danger  Space.— Fig.  14  shows  the  1000-yard  trajectory  of 
the  service  rifle.     The  line  DE  is  drawn  horizontal^  a  distance  of  8 


Fig 


feet  above  the  ground  Une  OX,  representing  the  height  of  a  cavalryman, 
the  line  FG  is  drawn  similarly  68  inches  above  the  ground  to  represent 
the  height  of  an  infantryman.  The  points  /,  d,  e,  and  g  are  projections 
of  the  intersections  of  these  horizontal  Hues  with  the  trajectory.  It 
will  be  seen  that  a  man  on  horseback  will  be  in  danger  in  the  fields  Od 


700       YAR05 


Fig.   15. 


and  eX,  while  a  man  standing  will  be  in  danger  in  the  fields  Of  and  gX. 
The  danger  space  is  the  territory  in  which  objects  are  Uable  to  be  hit. 
Fig.  15  shows  the  cavahy  and  infantry  danger  spaces  for  the  700- 
yard  trajectories  of  the  caliber  .45  Springfield  rifle  and  the  service 
rifle.  The  danger  space  of  the  former  is  quite  short,  while  that  of 
the  latter  is  continuous.  The  flatter  the  trajectory  the  greater  will 
be  the  danger  space  at  the  long  ranges,  as  shown  in  Fig.  13,  and  the 
greater  will  be  the  continuous  danger  space,  as  shown  in  Fig.  15. 


BALLISTICS  29 

In  order  to  increase  the  effectiveness  of  rifle  fire,  the  construction 
should  be  such  as  to  give  the  flattest  possible  trajectories.  Fig.  13 
shows  the  development  in  that  direction  in  this  country. 

(b)  Factors  that  Affect  the  Trajectory. — The  curvature  of  a  tra- 
jectory is  primarily  due  to  gravity.  It  is  obvious  that  if  two  guns  are 
fired  horizontally,  their  projectiles  traveling  at  such  velocities  that 
the  first  will  reach  a  1000-yard  target  in  one  second,  the  other  the  same 
target  in  two  seconds,  the  former  will,  at  the  target,  have  fallen  16.08 
feet  below  the  horizontal  plane  through  the  muzzle  of  the  gun,  while 
the  latter  will  have  fallen  64.32  feet.  The  projectile  traveHng  fastest 
will  have  the  flatter  trajectory.  In  order  to  obtain  a  flat  trajectory, 
therefore,  it  is  necessary  to  have  a  high  muzzle  velocity  and  a  low  air 
resistance. 

The  muzzle  velocity  of  a  projectile  depends  mainly  upon  the  charge, 
the  pressure,  and  the  weight  of  the  projectile,  and  is  Hmited  by  the  allow- 
able energy  of  recoil  and  the  attainable  strength  of  the  gun.  The 
weight  of  a  rifle  must  not  be  excessive,  its  recoil  must  not  be  too  great, 
and  the  bullet  must  not  be  too  light,  lest  it  have  insufficient  stopping 
power. 

(c)  Sectional  Density  and  Form. — While  it  is  important  to  improve 
the  interior  ballistics  of  a  gun  in  order  to  obtain  a  high  muzzle  velocity, 
it  is  equally  important  to  reduce  the  air  resistance.     The  formula 

0  c 

R  =  A„^  — rn>V^  is  an  expression  for  the  retardation  in  feet  per  second 
di  w/d'' 

due  to  the  resistance  of  the  air.  ^„  is  a  constant  depending  upon  the 
velocity  of  the  projectile,  obtained  from  a  ballistical  table;  V  is  the 
velocity  of  the  projectile  in  feet  per  second  and  n  is  a  number  depend- 

ent  on  the  velocity  considered,  ^  is  an  atmospheric  correction  ob- 
tained from  a  table  and  is  the  ratio  of  standard  density  of  atmos- 
phere to  the  density  of  atmosphere  at  time  of  firing;  and  " c"  is  a 
form  coefficient  determined  by  experiment.  The  term  w/d^  is  the  sec- 
tional density  of  a  projectile,  and  is  its  weight  in  pounds  divided  by  the 
square  of  its  diameter  in  inches.  From  the  formula  it  will  be  seen  that 
the  greater  the  sectional  density  the  less  will  be  the  retardation. 

In  order,  then,  to  improve  the  trajectory  by  reducing  the  air  resist- 
ance, it  is  necessary  to  increase  the  weight  of  the  projectile  and  to 
decrease  its  diameter.  A  projectile's  weight,  however,  is  dependent 
upon  the  muzzle  velocity  desired  and  the  recoil  of  the  gun  permitted, 
so  that  the  sectional  density  can  be  improved  mainly  by  decreasing  the 
diameter.     The  diameter,  on  the  other  hand,  it  must  be  remembered, 


30 


GUNSHOT   WOUNDS 


affects  the  destructive  capacity  of  the  projectile  and  in  small  arms 
projectiles  the  shock  effect. 

The  air  resistance  can  be  further  reduced  bj-  improving  the  pro- 
jectile's form.  Fig.  16  shows  the  relative  resistance  of  spherical-headed 
and  ogival-headed  projectiles.  The  resistance  to  the  ogival  head 
struck  with  a  radius  of  two  diameters  is  taken  as  unity.  The  resist- 
ance to  a  spherical  head  is  a  fourth  greater,  while  that  to  the  ogival 
head  of  7  diameters  radius  is  only  about  half  as  much.  In  addition 
to  pointing  projectiles,  experiments  are  under  way  with  rifle  bullets 
to  determine  the  effectiveness  of  a  rear  ogive  with  a  view  to  still  further 
reduce  the  retardation  due  to  the  air.  In  the  formula  above  the  effect 
of  a  projectile's  form  on  the  retardation  is  expressed  in  the  term  "c," 
which  is  determined  experimentally. 


RC5151AMCt=l.e7 


ID 
l.oS 


2D 
100 


3D 
82 

Fig.  16. 


4D 
7/ 


5D 
.64 


6D 
■  58 


70 
.54- 


THE  UNITED  STATES  OR  NEW  SPRINGFIELD  RIFLE 

The  present  service  rifle  was  adopted  in  1903  on  the  recommen- 
dation of  a  board  of  officers,  after  exhaustive  tests.  The  important 
changes  that  have  been  made  in  the  rifle  since  its  adoption  are  given 
below.  The  rear  sight  on  the  rifle  as  adopted  was  replaced  by  an 
improved  sight  in  1905.  Experiences  in  the  Russo-Japanese  War 
showed  that  it  was  essential  for  an  infantryman  to  have  a  serviceable 
bayonet,  and  as  a  result  the  rod  bayonet  was  displaced  in  1905  by  a 
long  knife  bayonet.  In  1906  a  sharp-pointed  bullet  was  adopted  and 
a  pj^rocellulose  powder  substituted  for  the  nitroglycerin  powder. 
These  changes  resulted  in  an  increased  range,  a  flatter  trajectory, 
and  a  longer  accuracy  life  due  to  decreased  erosion.  To  accommodate 
these  changes  a  slight  alteration  was  made  in  the  chamber  of  the  rifle. 

UNITED  STATES  RIFLE,  MODEL  OF  1903 

Weight  without  bayonet 8 .  69  pounds. 

Weight  with  bayonet 9.69  pounds. 

Capacity  of  Magazine 5  cartridges. 

Rifling,  uniform  twist,  one  turn  in  10  inches,  right  hand. 

Sighted  from  100  to  2850  yards. 

Diameter  of  bore 30  inch. 


BALLISTICS 


31 


BLXLET,  MODEL  OF  1906 

Length 1 .  095  inches. 

Maximum  diameter 3085  inch. 

Weight 150  grains  +  1  grain. 

Material  of  core 96 . 7  per  cent,  of  lead  and  3 . 3 

per  cent,  tin,  approximately. 
Jacket Cupro-nickel,  85  per  cent,  cop- 
per and  15  per  cent,  nickel. 
Charge,  pyrocellulose  powder,  determined  for  each 

lot  of  powder,  ordinarily  about 48  grains. 

Muzzle  velocity  of  bullet 2700  feet  per  second. 


U.  S.  :^Iodel  of  1903  U.  S.  Model  of  1906 

Cartridge.  Cartridge. 

Fig.  17. 


Fig.  17  shows  the  difference  between  the  model  of  1903  and  model 
of  1906  cartridges.  All  U.  S.  Army  rifles  have  now  been  chambered 
for  the  latter  cartridge. 

The  rifle  has  a  right-hand  twist,  and  the  drift  is  therefore  to  the 
right.  Due  to  a  slight  lateral  jump  to  the  left,  the  trajectory  is  found 
to  be  very  slightly  to  the  left  of  the  central  or  uncorrected  line  of  sight 


32  GUNSHOT   WOUNDS 

up  to  a  range  of  500  yards,  and  beyond  that  range  it  is  to  the  right  of 
this  hue.  The  drift  at  1000  yards  is  13  inches  to  the  right,  and  at 
2000  yards  about  12  feet.  The  drift  slot  on  the  rear  sight  leaf  is  so 
cut  as  to  partially  correct  for  the  drift. 

Recent  successes  in  the  Pan-American,  Olympic  and  Palma  com- 
petitions demonstrate  that  we  have  the  most  accurate  rifle  in  the  world. 
With  a  high  muzzle  velocity  and  a  flat  trajectory,  little  remains  to 
be  desired  in  the  present  rifle  unless  the  trajectory  can  be  further 
lowered  and  the  continuous  danger  space  for  a  height  of  68  inches 
extended  from  the  present  range  of  730  yards  to  a  range  of  1000  yards. 

The  automatic  rifle  will,  no  doubt,  be  the  military  weapon  of  the 
future.  All  nations  have  experimented  with  rifles  of  this  type,  but 
so  far  as  is  known  no  nation  has  succeeded  in  finding  an  automatic 
rifle  sufficiently  reliable  and  effective  in  the  hands  of  troops  to  justify 
the  expense  of  adopting  it  in  place  of  the  rifles  now  in  use.  In  1909 
the  Mexican  Government  ordered  4000  Mondragon  automatic  rifles. 
This  gun  uses  the  same  cartridge  as  the  Mauser  rifle  with  which  the 
Mexican  troops  are  armed. 

The  following  table  shows  the  different  features  of  the  reduced 
caliber  rifles  now  in  use  by  the  armies  of  the  world. 


RIAL,  AND  QUALITIES 
waff  en von 


Powder 

Bullet 

Cartridge 

Initial 

velocity 
m. 

Kind 

Form 

"Weight 

of 
charge 

^hape 

Coating 

Core 

Length 
mm. 

Weight 
S. 

Weight 
S. 

Number 

rounds 
per 
man 

Graicotton 

Flakes 

2.65 

OgiTal 

Nickel-plated 
steel  sheet 

Hard  lead 

30.7 

13.7 

26.8 

120 

630 

Gnncotton 

Disks 

2.75 

Ogival 

Steel  sheet 
(Oiled) 

Hard  lead 

31.8 

15.8 

28.68 

140 

620 

Guncotton 

Flakes 

2.5 

Ogival 

Nickel-plated  steel  sheet 

Hard  lead 

30.2 

14.1 

28.0 

120 

600 

Guncotton 

Flakes 

2.7 

Ogival 

Nickel-plated  steel  sheet 

Hard  lead 

31.8 

15.8 

28.75 

120 

620 

Guncottou 

Flakes 

2.20 

Ogival 

Cupro-nickel 

Hard  lead 

30.25 

14.5 

30.0 

120 

610 

Guncotton 

Flakes 

l2.75or 
[2.90 

Ogival,  some- 
what, flattened; 
or  pointed 

Nickel  or 
without 

Hard  lead 
or  copper 

30.30 

or 

39-2 

15.0 
or 
13.0 

29.40 
or 

27.60 

120 
120 

610 
or 

700 

Mjuncotton 

Flakes 

2.63 
3.20 

Ogival 
Pointed 

Steel  sheet  coated 
f        with  copper 

Hard  lead 
Soft  lead 

31.25 
28.0 

14,7 
10.0 

27.88 
23.75 

120 
150 

620 
860 

Nitroglycerin 
Nitroglycerin 

Threads 
Threads 

2.08 
2.06 

Round 
Roimd 

Cupro-nickel 
Cupro-nickel 

Hard  lead 
Hard  lead 

31.85 
32.10 

13.82 
13.86 

27.40 

27.48 

115 
100 

610 
605 

Guncotton 

Disks 

2.43 

Ogival 

Steel  coated  with 
cupro-nickel 

Hard  lead 

31.44 

10.33 

22.1 

? 

720 

Nitroglycerin 

Tubes 

2.25 

Ogival  some- 
what flattened 

Cupro-nickel    (Oiled) 

Hard  lead 

30.2 

10.50 

22.0 

162 

700 

Guncotton 

Flakes 

2.14 

Slender  Ogival 

Cupro-nickel 

Hard  lead 

32.60 

10.50 

22.41 

135  + 

710 

Guncotton 

Flakes 

2.00 

Ogival 

Cupro-nickel 

Hard  lead 

32.2 

10.52 

21.8 

120-150 

690-700 

Guncotton 

Flakes 

2.45 

Ogival 

Nickel-plated  steel  sheet 

Hard  lead 

30.92 

10.2 

22.61 

160 

720 

Nitroglycerin 

Flakes 

2.30 

Ogival 

Nickel-plated  steeLsheet 

Hard  lead 

32.15 

10.10 

23.55 

150 

700 

Guncotton 

Flakes 

2.91 

Ogival 

Steel  coated  with 
Cupro-nickel 

Hard  lead 

32.0 

10.10 

24.10 

y 

720 

Guncotton 

Flakes 

2.31 

Ogival 

Steel  coated  with 
Cupro-nickel 

Hard  lead 

31.36 

10.33 

22.72 

130 

710 

i 

Guncotton 

Flakes 

2.48 

Ogival 

Cupro-nickel    COUed) 

Hard_lead 

30.2 

13.75 

25.80 

120 -j- 

620 

1    V_   Gun- 
1    f     cotton 

j  J 

>-Flakes 

2. .54 

From 

V2.i5 

to 

2.55 

>    Ogival 

>•      Cupro-nickel 

.Hard 
lead 

30.30 

From 

>30.25 

to 

30.86 

41.20 

From 

>.2t.60 

to 

24.96 

From 
J.  120 
to 
150 

Between 
>     690 

and 
700. 

'     Guncotton 

1 

Flakes 

2.36 

Ogival 

Cupro-nickel 

Hard  lead 

32.12 

10.12 

23.55 

120 

710 

Guncotton 

\ 

Vermicelli 

2.0 

Ogival 

Steel  coating,  with 
paper- wrapping  (oiled) 

Hard  lead 

31.7 

13.9 

27.5 

150 

600 

1 

Guncotton 

Flakes 

2.65 

Ogival 

Nickel-plated  steel 
sheet 

Hard.lead 

30.7 

13.7 

26.8 

120*1' 

630 

TABLE  1. 

RIFLES  NOW  IN   USE:  BRIEF  COMPARISON  OF  DATA  ON  THEIR  CONSTRUCTION,  MATERIAL,   AND  QUALITIES 

(Translated  by  V.J.  from  the  "Tabelle  2"  appended  to  "Die  Entwicklung  der  Handfeuerwaffen von 

G.  Wrzodek Leipzig 1 908" ) 


Sigbt 


ElDd  of  MaffazlDQ 


_n^ 


twu  klDtls  uf  ommuultlon 

r  (m.)  -  39.371  iaohoa.       1  mlUL 


•j"  Afcordiug  to  njwut.iuformation  the  number  of  rounds  carried  by  men  Is  to  bo  increased  to  150  per 
,oter  (mm.) -.039371  Inoh.        1  kiloaram  (kg.)  =2.2046  pounds.        1  gram  (g.)  =  15.4324  grainfl  =  .036274 


CHAPTER  II 

The  Characteristic  Lesions  Caused  by  Projectiles 

Wounds  by  Projectiles  from  Hand  Weapons. — No  chapter  in 
surgery  has  undergone  such  radical  changes  as  that  pertaining  to  gun- 
shot wounds.  The  wounds  from  firearms  have  received  benificence, 
like  all  wounds,  from  modern  methods  of  treatment;  but  aside  from 
this,  wounds  from  weapons  like  the  military  rifle  are  not  at  all  times 
so  extensive  in  their  pathological  characters  as  they  were  formerly, 
and  they  are  more  amenable  to  treatment. 

To  understand  the  characteristic  appearances  of  bullet  wounds  in 
general,  we  will  first  consider  the  effect  of  the  old-time,  larger,  and  lower 
velocity  projectiles,  as  compared  to  those  of  more  recent  times. 

The  Old  Round  Balls. — These  were  usually  composed  of  soft 
lead  under  the  name  of  musket  balls  of  about  .72  to  .75  calibers, 
having  an  initial  velocity  of  600  to  767  f.s.  With  these  low 
velocities,  spherical  balls  showed  destruction  of  an  amount  of  tissue  in 
soft  parts  coincident  with  the  diameter  of  the  projectile.  The  mechani- 
cal effects  of  such  a  bullet  were  more  that  of  stretching  the  tissues  to 
permit  the  passage  of  the  missile.  The  wound  of  entrance  was  round, 
the  size  of  the  bullet,  with  a  punched-out  appearance,  and  it  was  sur- 
rounded by  a  more  or  less  extensive  ecchymosis.  The  track  of  the 
bullet  was  identified  by  a  channel  of  devitalized  tissue  greater  than  the 
diameter  of  the  ball.  The  exit  wound  in  the  skin  was  always  greater 
than  the  entrance  wound,  triangular  or  star-shaped,  with  everted 
edges  having  the  appearance  of  an  injury  inflicted  by  a  force  exerted 
from  within. 

The  effects  of  the  old  spherical  bullet  on  bone  was  marked  by  lodg- 
ment in  a  large  proportion  of  the  cases,  and  flattening  of  the  projectile 
itself.  When  propelled  by  its  maximum  velocity  of  translation,  the 
bullet  was  capable  of  causing  extensive  damage,  though  less  than  that 
observed  from  the  conoidal  rifle  bullets  of  a  later  date.  The  force  of 
impact  caused  extensive  comminution,  with  displacement  of  spiculse 
about  the  line  of  flight  of  the  bullet.  Fissures  were  seen  in  the  shaft 
above  and  below  the  area  of  fracture.     This  bone  lesion,  added  to  the 

33 


34 


GUNSHOT   WOUNDS 


extensive  trauma  in  soft  parts,  made  the  gunshot  wounds  of  that 
era  prone  to  suppuration  and  dangerous  to  hfe. 

The  Cylindro-conoidal  Bullet. — The  use  of  elongated  bullets  was 
coincident  with  the  adoption  of  the  hand  rifle.  The  earlier  types  were 
fired  from  the  Minie  rifles,  so-called,  and  later  as  the  guns  became  more 
perfect,  the  initial  velocity  was  increased  accordingly.  The  accom- 
panying chart  gives  the  ballistic  data  and  development  stages  of  old- 
time,  and  modern  firearms  used  in  war. 

The  wounds  by  the  elongated  bullets,  from  the  beginning,  caused 
enormous  destruction  of  tissue,  and  as  the  arms  from  which  they  were 


Fig.  18.- 


-Lodged   spherical    soft-lead    ball.     Amputation    lower   third    thigh. 
Museum.     Specimen  from  Civil  War,  1861-65. 


No.    4063   A.    M. 


propelled  became  more  and  more  perfect,  the  severity  of  the  wounds 
increased  so  markedly  that  accusations  and  recriminations  of  the  use 
of  explosive  bullets  were  commonly  made  by  combattants  in  the 
beginning  of  every  war.  The  pathological  appearances  of  a  gunshot 
wound  of  the  shaft  of  a  long  bone,  were  so  much  like  the  destruction 
wrought  by  a  hollow  bullet  loaded  with  an  explosive,  that  it  was  not 
until  the  mechanics  of  the  projectiles  had  been  properly  understood 
that  a  satisfactory  and  convincing  explanation  of  their  effects  was 
made. 

The  aim  of  the  balhsticians,  in  perfecting  the  military  rifle,  from 
the  beginning  was  directed  toward  an  increase  in  the  velocity  of  the 
projectile.  This  was  done  by  accomplishing  a  perfect  fit  of  the  pro- 
jectile in  the  barrel  to  prevent  the  escape  of  powder  gases.  The  effect 
of  this  plan  on  the  large  calibers  in  use  at  the  time  of  the  transition, 


CHAKACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


35 


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36 


GUNSHOT   WOUNDS 


from  the  smooth  bore  to  rifle  weapons,  was  to  add  im.mensely  to  the 
recoil.  The  latter  became  such  a  tax  on  the  soldier's  endurance  that 
it  was  necessary  to  reduce  the  caliber  and  the  amount  of  the  explosive 
as  well.  Increase  in  velocity  and  reduction  in  caliber  materially  added 
to  the  penetration  of  bullets.  The  wounds  produced  in  soft  parts 
were  not  attended  with  so  much  contusion  and  laceration  as  with  the 
use  of  the  old  spherical  balls.  The  amount  of  devitalized  tissue  sur- 
rounding the  track  was  less — the  wound  was  more  clean  cut  as  it  were. 
Bone  Injuries  by  the  Cylindro-conoidal  Bullets. — When  a  45  cali- 
ber bullet  or  a  projectile  from  any  of  the  larger  caliber  rifles  mentioned 


Fig.  19. — Lodged  conoidal  ball,  radiating 
fFacture.  No.  3175  A.  M.  Museum.  Spec-i- 
men  from  Civil  War,  1861-65. 


Fig.  20. — Lesion  by  conoidal  ball. 
From  amputated  limb.  No.  3245  A.  M. 
Museum.  Specimen  from  Civil  War, 
1861-65. 


happened  to  collide  with  a  resistant  bone,  like  the  diaphysis  of  the 
hum.erus  or  femur,  the  destructive  appearance,  as  already  stated, 
resembled  the  effects  of  an  explosion  having  taken  place  from  within 
and  the  pathologic  concUtion  was  generally  described  in  the  literature 
of  gunshot  wounds  under  the  term  of  Wounds  Having  Explosive  Ef- 
fects. The  characteristic  lesions  were  notably  seen  in  the  proximal 
ranges — from  the  muzzle  up  to  about  350  yards.  Except  for  close 
shots  at  contact  or  nearly  so,  the  wound  of  entrance  presented  no 
special  features.     When  it  was  located  in  skin  overlying  bone,  as  over 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  37 

the  tibia,  bony  sand  was  noted  at  the  wound  of  entrance  in  a  cer- 
tain proportion  of  the  cases.  The  point  of  impact  against  resistant 
bone  showed  loss  of  substance,  the  bone  was  finely  comminuted,  and 
radiating  from  this  point  larger  spiculse  of  bone,   some  entirely  de- 


FiG.  21.  Fig.  22. 

Fig.  21. — Caliber  .50  conoidal  bullet  lodged  against  plantar  surface  right  foot.  Partial  frac- 
ture of  cuboid  and  cuneiform  bones.  Primary  amputation  by  Chapart's  method.  Died  ninth 
day  of  typhoid  fever.     No.  6531  A.  M.  M.     Specimen  from  Civil  War,  1861-65. 

Fig.  22. — X-ray  print  of  left  leg  of  a  Civil  War  (1861-65)  veteran  showing  lodged  large  caliber, 
soft  lead,  fragmented  bullet,  lying  between  tibia  and  fibula  anteriorly  just  below  superior  fibulo- 
tibial  articulation,  where  it  can  be  easily  palpated.  Missile  entered  leg  posteriorly  in  median  line  of 
calf,  about  3  inches  below  knee-joint  and  passed  directly  forward,  apparently  without  seriously 
injuring  the  bones  and  lodged  anteriorly  as  shown.  The  bullet  was  fragmented  by  bony  contact 
in  its  passage  through  the  leg.  Endeavor  waS-made  on  the  battle  field  to  extract  the  bullet  by  the 
fingers  passed  through  the  wound.  Wound  was  infected  and  discharged  pus  for  three  or  four  months 
Since  healing  of  parts  there  have  been  no  symptoms  of  pain,  atrophy,  etc.  Exposure  made  in  1912. 
Army  Med.  School  collection.     H.  P.  Pipes,  Capt.,  Med.  Corps,  U.  S.  A.  X-rayist. 

tached,  were  driven  into  the  soft  parts  in  the  line  of  flight  of  the  bullet 
and  at  right  angles  to  the  direction  of  the  moving  body.     Pulpification 


38 


GUNSHOT    WOUNDS 


of  soft  parts  was  noticed  at  some  distance  from  the  track  of  the 
bullet,  as  a  result  of  the  penetration  and  laceration  by  particles  of 
bone,  and  as  often  happened,  disintegrated  particles  of  the  bullet 
which,  taking  part  of  the  projectiles'  energy  and  acting  as  secondary 
missiles,  added  to  the  destructive  effects.  The  wound  of  exit  was 
irregular,  and  measured  as  much  as  3  and  4  inches  in  its  longest 
diameter.  The  space  from  the  wound  of  exit  to  the  point  of  impact 
on  the  bone  was  conical  in  shape,  with  the  base  of  the  cone  correspond- 


FiG.  23. — Recent  skiagram  in  case  of  Maloy  W.  Rock,  Co.  "C,"  1st  Va.  Cavalry.  Shot  by 
conoidal  bullet  in  Civil  War,  1864.  Some  pain  in  region  of  bullet  not  enough  to  prevent  him 
from  his  usual  work.     X-ray  Laboratory  National  Home  for  D.  V.  S.,  Marine  Barracks. 


ing  to  the  wound  of  exit,  and  the  apex  to  the  seat  of  fracture.  There 
was  usually  more  or  less  Assuring  of  the  shaft  radiating  from  the 
fractured  ends.  Beyond  the  zone  of  explosive  effects  fragmentation 
was  not  so  marked,  there  was  absence  of  bony  sand;  the  fragments  were 
not  so  much  displaced.  The  wound  of  exit  was,  however,  perceptibly 
larger  than  the  wound  of  entrance  and  this  fact  was,  as  a  rule,  a  pretty 
sure  indication  of  bone  lesion. 

When  the  conoidal  bullets  happened  to  collide  with  the  epiphyseal 
ends  of  the  long  bones  in  the  proximal  ranges  the  softer  bone  was 
broken  into  many  fragments,  with  less  tendency  to  displacement  of 
fragments  than  noted  in  the  more  brittle  osseous  structures.     There 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


39 


was  more  bone  dust  and  greater  tendency  to  entire  loss  of  substance 
at  the  point  of  impact,  with  httle  or  no  fissuring  of  the  shaft.  At  longer 
ranges — 500  to  1500  yards — the  bullets  showed  a  tendency  to  perforate 
the  epiphyseal  structure  with  no  splinters  nor  fissures  resulting.  The 
pathologic  lesion  was  a  complete  perforation,  resembling  a  hole  made 
by  a  drill.     The  cause  of  the  difference  in  the  lesion  noted  between  the 


i 

i^^^^H 

#§ 

.   1 

\  i^v  ft  % 

{•'  •! 

i  ^^jv'4 

4'' 

vv^^L  A 

1 

1 

j,i 

• 

'M 

i, 

^^IH  * 

JS9^ 

■— -fet  -.rlM 

Wk 

^^H[^^^Bk»_    *  lo^K 

^^^HBH^H 

Fig.  24. — Anterior   and  posterior  views.     Fracture   at  base   of  trochanters.     Note  long  fissures. 
Lodged  deformed  conoidal  ball.      No.  87,  A.  M.  M,     Specimen  from  Civil  War,  1861-65. 


middle  of  the  shaft  and  the  joint  end  of  a  long  bone  lay  in  the  degree  of 
resistance  offered — the  bone  of  the  shaft  being  hard  and  more  brittle, 
that  of  the  epiphysis  being  soft  and  spongy. 

The  amount  of  destructuve  effects  in  bone  was  always  coincident 
with  (a)  resistance  on  impact,  (b)  sectional  area  of  the  bullet  and  (c) 
its  velocity.  The  theories  advanced  to  explain  these  so-called  explo- 
sive effects  will  be  taken  up  later. 


40 


GUNSHOT   WOUNDS 


Fig.  25. — Anterior  and  posterior  views  of  fracture  right  femur  from  conoidal  ball.     Amputation 
(_ third  day;  died  nineteenth  day.      No.  2056  A.  M.  M.     Specimen  from  Civil  War,  1861-65. 


Fig.  26. — Perforation  by  musket  ball  of  epiphyseal  end  right  femur  with  long  fissures  in  shaft. 
Limb  amputated;  death  on  fourteenth  day.     No.  76,  A.  M.  M.     Specimen  from  Civil  War,  1861-65. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  41 

Injuries  by  Steel  Armored  Bullets  from  Reduced  Caliber  Rifles. — 
Our  first  knowledge  of  the  effects  of  steel-clad  bullets  came  to  us  from 
certain  experiments.  The  experimenters  were  at  the  onset  con- 
fronted with  the  difficulty  of  hitting  one  particular  anatomical  part 
— the  femur  or  tibia  for  instance — at  anj^hing  like  battle  ranges. 
Obviously  experiments  at  the  actual  ranges  must  have  consumed 
much  time  and  material,  and  observers  in  the  experimental  field 
followed  the  plan,  which  is  common  ^\dth  gun  makers  in  like  cases,  of 
employing  simulated  ranges,  i.e.,  by  regulating  the  charge  in  such 
amount  as  to  confer  the  remaining  velocity  which  might  be  required 
at  am"  given  distance.  In  a  series  of  experiments  which  we  conducted 
at  Frankford  Arsenal,  Philadelphia,  in  1893,  we  fired  into  cadavers  at 
a  fixed  distance  of  53  feet,  and  from  this  distance,  by  graduating  the 
charge,  we  were  able  to  note  the  effects  of  bullets  on  different 
parts  of  the  human  body  at  all  ranges  from  100  to  2000  yards. 

The  results  which  were  thus  obtained  were  subsequently  criticised 
from  many  quarters.  It  was  claimed  that  the  experimental  shots 
against  bone  and  closed  cavities  containing  fluid  contents  gave  ex- 
aggerated results  as  compared  to  what  was  seen  in  war  subsequently. 
Some  of  the  critics  attributed  these  discrepancies  to  the  use  of  dead 
tissues  as  compared  to  the  effects  of  the  same  projectiles  on  the  living, 
and,  again,  it  was  claimed  that  the  velocity  of  rotation  of  the  elongated 
bullets  was  different  in  the  shots  at  simulated  ranges  as  compared  to 
what  it  would  be  at  normal  ranges. 

In  addition  to  our  own  experiments  with  this  method,  Delorme  and 
Chavasse  in  France,  Kocher  at  Berne,  Paul  Bruns  of  Germany,  and 
others,  employed  the  method  which  we  pursued.  The  conclusions 
arrived  at  independently  by  the  experimenters  were,  generally  speaking, 
about  the  same.  They  related  principally  to  the  humane  features  of 
the  wounds  caused  by  the  new  bullet  on  some  tissues,  and  the  explosive 
effects  noted  on  others,  but,  generally  speaking,  the  bullet  was  looked 
upon  as  likely  to  play  the  part  of  a  humane  instrument  in  the  wars  of 
the  future. 

Later,  Demosthen,  Yon  Coler,  Schgerning  and  others  shot  into 
cadavers  with  full  charges  at  actual  ranges  and  they  arrived  at  differ- 
ent conclusions  to  those  of  the  observers  who  had  shot  at  similated 
ranges.  They  claimed  that  the  explosive  effects  at  the  proximal 
ranges  were  less  with  the  use  of  normal  charges,  and  that  the  destruc- 
tive effects  became  perceptibly  less  as  the  range  was  increased. 

In  recent  years  the  results  from  the  Spanish-American,  Boer, 
Russo-Japanese  and  the  recent  Turko-Balkan  wars  have  come  up  for 


42  GUNSHOT   WOUNDS 

comparison  with  the  work  of  the  experimenters.  The  war  wounds  are 
thought  by  some  critics  to  be  but  httle  different  to  those  obtained 
from  experimental  shots,  while  quite  a  number  of  the  critics  arraign 
the  expermienters  who  would  use  simulated  methods  on  putrid  flesh 
as  rank  exaggerators.  We  will  endeavor  to  show  that  the  work  of  the 
experimenters  was  not  done  in  vain.  By  comparing  photographs, 
dissections,  and  skiagrams  of  gunshots  on  cadavers  at  simulated  ranges 
with  similar  illustrations  obtained  in  recent  wars,  we  hope  to  show 
that  the  conclusions  of  the  experimeters  were  in  the  main  correct. 

While  visiting  at  Val  de  Grace  one  day  in  1900  the  writer  saw  an 
improvised  target  in  a  corner  of  the  enclosure.  He  afterward  saw  a 
student  dissecting  a  gunshot  fracture  of  the  tibia  in  a  cadaver  and  on 
inquiry  he  was  told  by  Surgeon  General  Dujardiu  Beaumetz  that  the 
method  of  firing  into  dead  bodies  for  the  purpose  of  teaching  the  ef- 
fects of  gunshots  in  war  had  been  practised  in  the  French  Army  for 
one  hundred  years.  Surgical  literature  gives  the  French  Army 
surgeons  the  front  rank  as  writers  on  Military  Surgery,  and  it  is  not 
reasonable  to  suppose  that  close  observers,  such  as  they  have  shown 
themselves  to  be,  could  pursue  a  method  so  long  when,  as  some  critics 
would  have  us  believe,  there  is  nothing  to  be  learned  from  it. 

We  are  willing  to  concede  that  a  dead  body  half  frozen  out  of  cold 
storage,  hardened  in  pickle;  or,  a  fleshy  body,  stiff  in  rigor  mortis, 
will  give  exaggerated  results  in  shot  fractures  of  the  diaphyses  of  the 
long  bones.  The  rigid  or  plastic  flesh  offers  more  resistance  and  the 
wound  of  exit  is  doubtless  larger  and  more  lacerated,  but  in  fit  sub- 
jects, the  effects  on  bones,  the  head,  the  chest,  abdomen  and  vessels 
will  compare  with  those  on  the  living  sufficiently  to  enable  one  to  form- 
ulate conclusions  that  in  the  main  are  correct.  The  class  in  operative 
surgery  in  the  U.  S.  Army  Medical  School  is  made  to  amputate  for 
gunshot  fractures  and  to  examine  by  dissection  the  lesions  in  gunshot 
injuries  in  various  parts  of  the  dead  body.  This  part  of  the  work  is 
always  compared  at  the  time  with  the  X-ray  findings  which  have  been 
previously  made  in  each  case. 

From  observations  and  experience  off  and  on  in  the  last  twenty- 
one  years  by  firing  experimentally  into  cadavers,  animals,  and  inan- 
imate matter,  and  later  from  opportunities  which  have  come  to  us  to 
see  the  comparative  effects  of  the  old  and  new  armaments  on  the  living 
in  peace  and  war,  we  beheve  that  the  experimental  way  is  the  best 
method  of  teaching  the  mechanical  effects  of  projectiles  on  tissues  in 
times  of  peace  at  least,  and  that  it  answers  as  a  valuable  guide  to  a 
correct  understanding  of  the  gunshot  injuries  observed  in  war. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


43 


Our  experiments  at  Frankford  Arsenal  were  conducted  under 
orders  of  the  War  Department  dated  July  20,  1892.  A  board  of 
officers  was  appointed  of  which  the  writer  was  the  medical  member, 
to  ascertain  the  ''effects  of  small  arms  firing  with  new  calibers  and 
velocities  on  the  human  frame."  In  order  to  make  the  results  more 
apparent,  the  board  followed  the  plan  of  — 

(1)  Noting  the  effects  of  a  projectile  of  larger  caliber  and  lower 
velocities  upon  different  parts  of  the  human  body  at  various  ranges. 

(2)  Noting  the  effects  of  the  projectile  of  a  reduced  caliber  rifle, 
having  greater  velocities,  upon  similar  parts  of  the  human  body  or  parts 
offering  about  the  same  resistance  at  similar  ranges. 

The  larger  weapon  selected  was  the  .45  caliber  Springfield  rifle  which 
had  formed  the  armament  of  our  foot  troops  since  1873  and  which 
compared  as  to  caliber,  weight  of  ball,  charge  of  powder,  and  ballistic 
details  to  the  Gras,  old  Mauser,  and  the  military  rifles  of  the  nations 
before  the  introduction  of  the  new  armament. 

The  smaller  caliber  weapon  furnished  the  board  by  the  Ordnance 
Department  was  known  as  the  Experimental  Springfield  rifle,  caliber 
.30.  Its  bullet  was  impressed  by  37  grains  of  Payton  smokeless  pow- 
der. This  gun  compared  favorably  with  the  rifles  of  reduced  caliber 
in  use  at  that  time  by  Germany,  France  and  Austria,  viz.,  the  Lebel, 
New  Mauser,  and  Mannlicker. 

The  more  important  ballistic  values  of  the  two  weapons  are  set 
forth  in  the  following  tables: 


VELOCITIES  OF  THE  PROJECTILES  OF  THE  TWO  GUNS 


Name  and  caliber  of  weapon 


1500    2000 
yards:  yards 


Springfield,  caliber  .45 1301 


676  '  531 


Experimental  Springfield,  caliber  .30 '     2000      1103  '  804  ,  627 


429 
495 


A  tackel  was  provided  to  suspend  the  cadavers  and  to  bring  the 
portion  of  the  body  to  be  fired  at  into  proper  position.  Each  projectile 
was  stamped  at  the  base  with  a  letter  or  number  for  identification  and 
all  bullets  were  collected  from  barrels  of  sawdust  placed  behind  the 
target.     Ten  years  after  the  termination  of  these  experiments  we  went 


44 


GUNSHOT   WOUNDS 


ENERGY  OF  THE  PROJECTILES 
(In  foot-pounds) 


i 

Name  and  caliber  of  weapon  ,      i     •+       Weight   Muzzle 

500     1000    1500 
yards  |  yards  yards 

2000 

yards 

f.s. 

Springfield,  caliber  .45 1301 

Experimental        Springfield,      2000 
caliber  .30. 

Grains 
500 
220 

1879 
1954 

846 
594 

507 
315 

313 
192 

204 
120 

to  war  with  Spain;  the  wounded  from  this  war  gave  the  first  oppor- 
tunity of  any  consequence  to  mihtary  surgeons  to  observe  the  effects 
of  reduced  caliber  bullets  on  the  living.  Before  this  we  had  depended 
upon  accidents,  suicides  and  reports  from  some  of  the  South  American 
revolutions,  but  the  latter  especially  were  meager  and  unreliable. 
In  the  battle  of  Santiago  the  United  States  troops  engaged  numbered 
about  ten  thousand  men,  those  of  the  enemy  approximately  the  same. 
Our  casualties  were  233  killed  and  1400  wounded.  Having  taken 
active  part  in  the  experimental  work  already  referred  to,  the  writer 
was  necessarily  very  m.uch  on  the  alert  to  compare  the  wounds  on  the 
living  in  war  with  those  he  had  so  often  witnessed  on  the  dead  in  peace. 
We  had  occasion  at  this  time  to  review  our  own  conclusions,  and  those 
of  other  experimenters,  with  the  experience  culled  in  and  after  the  bat- 
tle of  Santiago.  The  conclusions  of  the  experimenters  are  12  in  num- 
ber, and  they  appear  in  quotation  marks  with  a  running  comment,  as 
follows: 

(1)  The  experimental  evidence  showed  that  ''the  shock  impressed 
upon  a  member  increases  with  the  velocity,  whether  a  bone  is  traversed 
or  not.  It  is  always  greater  with  the  larger  caliber  leaden  project- 
ile." This  diminution  in  shock  has  been  one  of  the  serious  objec- 
tions advanced  against  the  adoption  of  the  small  bullet  by  military 
men.  They  feared  that  one  wound  would  not  suffice  to  throw  a  man 
hors  du  combat,  and  that  he  might  be  able  to  go  on  fighting  regardless 
of  the  fact  that  he  had  been  hit  a  number  of  times.  Whether  this 
is  true  of  savage  tribes,  or  horses  in  a  cavalry  charge,  it  is  not  true 
of  our  American  soldiers.  Upon  inquiry  among  line  officers  in  the 
Santiago  campaign,  we  learned  that,  as  a  rule,  to  which  there  were  very 
few  exceptions,  men  when  hit  fell  back  to  the  rear  at  once;  and  we  can 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


45 


testify  to  the  fact  that  scores  of  them  walked  back  to  our  hospital 
at  Siboney,  with  wounds  that  were  most  trifling  in  their  nature. 

(2)  "  The  explosive  effects  at  very  short  ranges  are  about  the  same 
for  the  two  projectiles  and  they  continue  so  up  to  about  350  yards." 
We  only  saw  one  case  which  approached  anything  like  explosive  effects 
in  Cuba.  That  was  the  case  of  a  captain  of  the  rough  riders,  shot  in 
the  lower  third  of  the  tibia.     The  wound  of  entrance  was  about  the 


Fig.  27. — Two  views  of  explosive  effects  from  Mauser  bullet  at  close  range  at  battle  of  Santiago. 
Radiograph  one  year  after  injury.     Army  Med.  School  collection. 


caliber  of  the  Mauser  bullet  that  had  inflicted  it,  and  the  wound  of 
exit  was  irregularly  round,  a  half-inch  in  diameter.  There  were  two 
smaller  wounds  near  the  wound  of  exit,  which  were  undoubtedly  made 
by  spiculse  of  bone  which  had  been  driven  forth,  acting  as  secondary 
missiles.  The  area  of  fracture  was  about  4  inches  above  the  ankle; 
it  was  marked  by  a  cavity  in  which  many  loose  fragments  of  bone  lay, 
none  of  them  measuring  more  than  a  half-inch.     The  wall  of  the  cavity 


46 


GUNSHOT   WOUNDS 


showed  bony  sand  driven  into  the  soft  parts.     The  infrequency  of 
explosive  effects  among  the  wounded  at  the  battle  of  Santiago  should 


Fig.  28.  Fig.  29. 

Fig.  28. — Photograph  of  a  butterfly  fracture  of  tibia;  experimental  specimen  from  cadaver 
by  the  reduced  caliber  bullet  at  1200  yards.  The  fissures  were  mostly  superiosteal  in  recent 
specimen.     Army  Med.  School  collection.  |tf\ 

Fig.  29. —  (1)  Guttering  of  tibia  and  transverse  fracture  from  vibratory  force  by  reduced  caliber 
bullet  at  1200  yards.  Experimental  specimen,  from  cadaver.  (2)  Complete  perforation  of  lower 
epiphyseal  end  of  tibia  with  slight  fissuring,  same  ammunition  as  No.  1  and  at  the  same  range. 
Bullet  replaced  in  perforation  by  photographer.     Army  Med.  School  collection. 

be  attributed  in  our  opinion  (a)  to  the  fact  that  the  vast  majority  of  the 
wounds  were  inflicted  beyond  the  zone  of  explosive  effects,  and  (b) 


CHAKACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


47 


since  explosive  effects  are  chiefly  to  be  noted  in  the  vital  parts  con- 
tained in  rigid  walls,  like  the  brain,  or  in  those  organs  containing  much 
fluid,  like  the  heart,  liver,  spleen,  the  alimentary  tract,  these  wounds 
with  explosive  effects,  so  destructive  to  tissue,  were  numbered  among  the 
dead — a  class  which,  unfortunate^,  the  surgeon  has  no  time  to  study 
on  the  battle  field  (Fig.  27). 

(3)  The  experimenters  found  that  "the  smaller  frontage  of  the 
jacketed  bullets  causes  them  to  inflict  injuries  resembling  subcutaneous 
wounds  when  the  soft  parts  alone  are  traversed,  and  that  the  small 


il 

Fig.  30. — Photograph  of  perforation  in  head  of  tibia  by  .30  cal.  German  silver-jacketed  bullet, 
shot  out  of  the  experimental  Springfield  rifle,  into  a  cadaver  at  a  simulated  range  of  1200  yards  by 
the  author.  Bullet  used  is  undeformed  and  shows  to  left  of  specimen,  (a)  Orifice  of  entrance;  (b) 
orifice  of  exit.     Army  Med.  School  collection. 


wounds  of  entrance  and  exit  and  the  narrow  track  of  the  missiles  were 
favorable  circumstances  to  rapid  healing."  The  truth  of  this  state- 
ment is  borne  out  by  the  experience  of  all  surgeons  in  the  Santiago 
campaign.     Flesh  wounds  healed  very  kindly  and  rapidly. 

(4)  This  conclusion  of  the  experimenters  refers  to  hemorrhage. 
Johann  Habart,  of  the  Austrian  Army,  who  paid  special  attention  to 
this  subject,  states  "that  the  blood-vessels  are  seldom  torn  by  the 


48 


GUNSHOT   WOUNDS 


small  jacketed  bullet,  and  that  when  wounded  they  are  not  closed  so 
easily  by  coagulation  as  those  severed  by  leaden  projectiles."  Some 
writers  have  deduced  from  this  statement  that  alarming  or  fatal 
hemorrhage  would  be  more  frequent  in  future  battles.  The  experience 
of  the  surgeons  with  the  line  before  Santiago  does  not  confirm  these 
apprehensions.  Of  the  1400  wounded  as  far  as  we  could  learn,  not  one 
died  of  external  hemorrhage.  The  brachial  and  femoral  were  tied  a  few 
times  in  the  base  hospitals  for  diffuse  aneurysm.  One  case  of  wound 
of  the  subclavian  was  operated  upon  in  New  York  and  died  and  there 


Fig-  31.  Fig.  32. 

Fig.  31. — Front  view.  Radiograph  iujcase  of  W.  K.  showing  perforation  of  upper  end  of 
tibia.  Wounded  June  25,  1899,  by  a  Krag-Jorgensen  bullet  at  a  distance  of  10  feet.  Radiograph 
taken  30  months  after  injury.  Remote  effects:  slight  weakness  and  pain  at  site  of  wound.  Good 
motion  in  joint.     U.  S.  Soldiers  Home  collection. 

Fig.  32. — Skiagram  showing  side  view  of  Fig.  31. 


were  jEive  cases  of  gangrene  from  injury  to  blood-vessels  which  required 
amputation. 

(5)  ''Injuries  inflicted  outside  the  zone  of  explosive  effects  upon 
the  shafts  of  the  long  bones  always  show  less  comminution  with  the 
small  bullet  of  hard  exterior.  The  fissures  are  often  subperiosteal,  and 
the  fragments  are  larger."  This  was  true  of  the  Mauser  bullet  wounds 
in  Cuba.  It  was  seldom  necessary  to  open  up  the  wounds  for  the  pur- 
pose of  taking  out  loose  fragments  of  bone.  In  a  number  of  instances 
there  was  distinct  guttering  of  the  compact  substance  of  long  bones 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


49 


without  fracture.  The  mobility  in  some  instances  was  so  shght 
that  it  was  difficult  to  make  out  a  complete  fracture  when  from  the 
location  of  the  wounds  it  was  certain  that  the  bone  had  been  traversed. 
^  (6)  "Beyond  the  zone  of  explosive  effects  the  projectiles  of  hard 
exterior  almost  invariably  perforate  or  gutter  the  joint  ends  of  bones, 
and  the  lesions  of  the  articulations  are  never  so  grave."  This  conclu- 
sion tallies  exactly  with  what  we  saw  in  Cuba.     We  do  not  recall  a 


Fig.  33. — Exit  wound  showing  explosive  effects  on  bone  by  Japanese  rifle  bullet  at  short  range. 
Russo-Japanese  War.      (Lynch.) 

formal  excision  of  a  joint  for  the  mechanical  effects  of  the  Mauser 
bullet.  Joints  were  opened  to  turn  out  blood  clots,  and  in  one  instance 
of  the  knee  we  particularly  remember,  to  locate  a  lodged  ball,  but 
never  for  the  purpose  of  performing  an  excision.  There  were  seventeen 
cases  of  gunshot  injury  to  the  knee-joint.  These  were  immobilized 
and  shipped  north;  and  82  per  cent,  of  them  were  restored  to  duty 
within  a  few  months.  These  results  are  a  great  contrast  to  gunshots 
inflicted  by  the  larger  leaden  bullet,  which  by  its  highly  destructive 
effects  must  have  caused  a  number  of  partial  resections  and  am- 
putations. 

(7)   ''The  projectiles  of  hard  exterior  lodge  less  frequently  in  the 
tissues  than  the  old  leaden  bullet."     The  experience  at  Santiago, 


50  GUNSHOT   WOUNDS 

among  the  wounded  of  both  sides,  has  shown  a  surprisingly  large 
number  of  lodged  balls.  Although  we  are  not  prepared  to  state  that 
the  small-caliber  bullet  lodges  as  often  as  the  old  discarded  leaden 
bullet,  the  frequency  with  which  it  did  lodge  was  commented  upon 
by  all  of  our  military  surgeons.  Dr.  W.  E.  Parker,  of  New  Orleans, 
an  acting  assistant  surgeon  in  the  base  hospital,  visited  the  Spanish 
hospitals  in  Santiago  after  the  surrender,  and  in  conversation  with 
the  Spanish  surgeons  he  learned  that  our  Krag-Jorgensen  bullet  had 
not  lodged  in  their  wounded  as  often  as  their  Mauser  bullet  had 
lodged  in  our  men.  The  explanation  for  this  would  seem  to  be  simple 
enough.  It  should  be  remembered  that  we  were  on  the  aggressive  in 
a  region  that  was  practically  unknown  to  our  troops,  while  the 
Spaniards  were  perfectly  familiar  with  every  foot  of  ground  over  which 
we  m.ust  make  the  advance.  As  trained  soldiers,  their  officers  had 
carefully  studied  the  range  at  every  point.  With  this  valuable  infor- 
mation in  their  favor  they  were  in  a  position  to  commence  an  effective 
fire  at  remote  ranges,  say  at  2000  yards  and  more.  We  could  not  locate 
them  as  soon  as  they  located  us,  and  when  we  did  locate  them,  we  had 
to  study  the  range  before  we  could  commence  an  effective  fire.  It  was 
while  we  were  locating  them  and  studying  the  range  and  gradually 
advancing  that  they  placed  so  many  balls  into  our  soldiers.  When 
we  did  commence  an  effective  fire,  we  had  reached  a  point  where  the 
remaining  velocity  of  our  bullet  on  impact  was  sufficient  to  carry  it 
through  the  body.  There  is  another  explanation  which  might  be  at- 
tributed to  the  difference  in  the  energy  of  the  two  bullets  at  remote 
ranges.  Our  bullet  being  larger  and  heavier  than  the  Mauser  has 
greater  energy  at  2000  yards,  and  it  will  penetrate  farther  in  the  remote 
ranges  than  theirs.  Again,  ricochet  shots,  from  the  thick  underbrush 
and  broken  ground,  undoubtedly  favored  a  certain  percentage  of  lodg- 
ments. Many  of  the  officers  attributed  the  lodgm.ent  of  projectiles  to 
the  use  of  defective  ammunition  used  by  the  enemy.  This  point  was 
so  susceptible  of  proof  that  we  instituted  experiments  to  show  the  rela- 
tive penetration  of  the  Mauser  and  Krag-Jorgensen  rifles.  The  tests 
were  made  in  large  blocks  of  well-seasoned  yellow  pine  fired  into, 
across  the  grain,  3  feet  from  the  muzzle.  The  penetration  of  the 
Krag-Jorgensen  ammunition  was  24  inches  plus,  while  that  of  the 
Mauser  ammunition  exceeded  ours  by  nearly  10  inches,  a  demonstra- 
tion which  at  once  set  at  rest  the  idea  of  lodgment  from  the  defective 
ammunition  of  the  enemy. 

(8)   "The  old  leaden  bullet  more  often  leaves  fragments  of  lead  in 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  51 

the  foj-er  of  fracture."  This  is  so  true  that  it  needs  no  contradiction. 
The  leaden  bullet  was  so  soft  that  it  often  separated  into  a  number  of 
fragments  upon  striking  resistant  bone,  while  the  steel-jacketed  bul- 
let, as  is  well  known,  seldom  encounters  resistance  enough  in  the  human 
body  to  disintegrate  it. 

(9)  "As  the  projectiles  of  smaller  caliber  are  less  apt  to  lodge  or 
to  carr}'  foreign  substances  into  the  wounds,  we  will  expect  to  find 
fewer  cases  of  suffering  due  to  the  remote  effects  of  unextracted  foreign 
bodies."  This  is  true  of  the  smaller  bullet,  as  shown  in  Cuba.  There 
were  but  few  instances  where  clothing  or  part  of  the  equipment  was 
carried  into  the  wound. 

(10)  "The  frontage  of  the  jacketed  bullet  being  much  less  and  the 
fact  that  it  does  not  lodge  as  often  as  the  larger  leaden  bullet  will  serve 
to  increase  the  percentage  of  recoveries  in  gunshot  wounds  of  the  lungs." 
That  was  especially  true  of  the  wounded  in  Cuba.  As  a  rule  the 
wounds  of  the  lungs  were  apparently  so  trivial  that  it  was  difficult  to 
restrain  the  men  in  the  recumbent  posture. 

(11)  "Owing  to  diminished  frontage  the  new  bullet  will  cause  less 
disfigurements  in  wounds  of  the  face."  That  was  especially  true  of 
three  officers  who  received  painful  wounds  of  the  face. 

(12)  "The  projectiles  of  hard  exterior  are  more  humane  than  the 
old,  resections  and  amputations  will  not  be  so  often  required  here- 
after, soldiers  wall  be  more  often  restored  to  the  State  useful  members 
of  the  community  instead  of  cripples  and  pensioners,  and  in  point  of 
economy,  the  new  projectile  will  confer  a  great  advantage."  This 
last  conclusion  is  also  in  accordance  with  the  experience  in  Cuba. 
There  were  but  three  primar}^  amputations  and  not  one  of  them  was 
done  for  injury  by  the  small  bullet.  They  were  all  the  result  of  shell 
injuries.  From  the  foregoing  we  believe  that  the  work  of  the  experi- 
menters agrees  with  the  conditions  found  in  war,  and  that  their  work 
was  not  done  in  vain.  Furthermore,  we  may  state  that  we  are  not 
acquainted  vnth  any  experimenter  who  is  ready  to  repudiate  his  work 
as  futile. 

SOME  FURTHER  OBSERVATIONS  ON  WOUNDS  BY  MILITARY 
RIFLES  IN  RECENT  WARS 

In  the  Spanish-American  War  the  Spaniards  were  armed  with 
the  Spanish  Mauser  of  27.6-inch  caliber,  weight  of  projectile  172 
grains,  with  ogival  head,  and  a  muzzle  velocity  of  2296  f.s.     The  United 


52  GUNSHOT    WOUNDS 

States  troops  were  armed  with  the  Krag-Jorgensen  rifle,  of  .30-inch 
caliber,  weight  of  projectile  220  grains,  with  ogival  head,  and  initial 
velocity  of  2000  f.s.  In  the  Boer  War  the  latter  were  armed  princi- 
pally with  the  Spanish  Mauser,  whose  features  are  like  those  mentioned 
above,  some  Krag-Jorgensen  and  Alartini-Henrys,  but  the  bulk  of 
the  wounds  came  from  their  service  weapon,  the  Spanish  Mauser. 
The  British  troops  used  the  Lee-Enfield  of  .303  diameter,  with  a  muzzle 
velocity  of  2060  f.s.,  weight  of  projectile  215  grains.  In  the  Russo- 
Japanese  War  the  Russians  were  armed  with  the  Mossin-Nagant  of 
.  30-inch  caliber,  with  a  muzzle  velocity  of  1985  f.s. ;  weight  of  projectile 
214  grains.  The  first  and  second  lines  of  Japanese  troops  were  armed 
with  a  more  perfect  type  of  gun  as  follows:  the  Arisaka  of  25.6  caliber, 
muzzle  velocity  2390  f.s.,  weight  of  projectile  162  grains.  The  rest 
of  their  army  was  armed  with  a  gun  which  corresponds  to  our  Krag- 
Jorgensen  of  ten  years  ago.  In  the  Turko-Balkan  War  of  1912-13, 
the  Balkan  states  were  armed  with  the  Mannlicher  rifle  of  reduced 
caliber  which  about  corresponds  to  our  Krag-Jorgensen  rifle  with  the 
ogival-headed  bullet  used  by  our  troops  in  the  Spanish- American  War. 
The  military  rifle  of  the  Turks  was  the  German  Mauser,  which  fires 
the  pointed  bullet.  This  projectile  was  recently  adopted  by  the  Eng- 
lish and  U.  S.  Armies.  It  was  never  used  in  campaign  until  the  recent 
war  between  Turkey  and  the  Balkan  States. 

It  will  be  seen  therefore  that  the  hand  rifle  of  the  combatants  of 
all  armies  except  the  first  and  second  lines  of  Japanese  troops  and  the 
German  Mauser  of  the  Turks  which  fired  the  pointed  bullet  were  the 
same  in  ballistic  value.  Taken  as  a  whole  there  was  no  difference  in 
the  penetration  or  smashing  effects  of  the  bullets  worthy  of  consider- 
ation with  the  possible  exception  of  the  162-grain  bullet  of  the  Japanese 
Army,  which  was  more  humane  and  the  pointed  bullet  of  the  Turks, 
in  the  recent  Turko-Balkan  War  whose  deadly  effects  will  be  com- 
mented upon  later. 

Wound  of  Entrance  — With  high  velocities  the  wound  of  entrance 
is  apt  to  be  larger  than  we  find  it  at  mid  and  remote  ranges.  The 
wound  is  round  when  the  bullet  strikes  perpendicularly,  and  oval  if 
it  impinges  obliquely.  The  regularitj^  of  the  circle  or  oval  is  seen 
oftener  in  skin  that  is  well  supported.  Entrance  wounds  in  skin 
overlying  bone  as  that  over  the  sacrum,  anterior  part  of  tibia,  and 
sternum,  are  larger  than  the  projectile.  In  skin  overlying  loose  areo- 
lar tissue  like  the  scrotum,  the  entrance  wound  is  less  regular,  slit- 
like, and  apparently  smaller  than  the  diameter  of  the  bullet.     When 


CHARACTERISTIC    LESIONS    CAl'SED   BY    PROJECTILES  53 

by  ricochet  or  otherwise  the  bullet  strikes  side  on  or  ''butt  end  to" 
the  entrance  wound  is  irregular  and  lacerated.  The  edges  of  the  wound 
are  apt  to  be  inverted  or  depressed  for  a  short  time,  and  covered  with 
a  dark  gray  substance,  more  than  likely  dirt,  resulting  from  the  gases 
of  explosion.  Underneath  the  dark  stain  appears  the  pink  cuticle 
denuded  of  epithelium,  by  the  friction  of  the  projectile.  This  pink 
rim  soon  dries  and  turns  brown  in  color.  Slight  ecchymosis  appears 
later  about  the  entrance  wound,  but  it  is  never  so  well  marked  as  in 
the  case  of  the  older  and  larger  caliber  bullets. 

Wound  of  Exit. — These  wounds  are  more  variable  in  extent  and  shape 
than  the  wounds  of  entrance.  Again  with  maximum  velocities,  pro- 
vided no  bone  lesion  is  present,  the  exit  aperture  is  often  difficult  to 
discriminate  from  the  entrance  wound.  The  two  wounds  may  be 
equal  in  size,  the  entrance  wound  mah"  show  inverted  edges,  while 
in  the  exit  wound  the  edges  are  generalh'  everted.  When  the  bullet 
has  passed  through  soft  parts  alone,  the  exit  wound  is  apt  to  be  cir- 
cular in  shape.  In  loose  skin,  with,  low  velocities,  the  exit  wound  is 
apt  to  be  lacerated,  and  when  the  velocity  is  high  it  is  apt  to  be  marked 
by  a  mere  sUt.  The  greatest  extent  of  traumatism  with  maximum 
irregularity  is  seen  in  exit  wounds  following  bone  lesions.  The  lesion 
of  hard  bone,  like  the  diaphysis  at  close  range,  shows  maximum  wounds 
of  exit.  Such  wounds  present  typical  explosive  effects.  The  exit 
wound  in  the  skin  may  be  several  inches  in  diameter. 

With  the  high-power  militar}^  and  sporting  rifles  the  track  of  the 
bullet  is  marked  by  a  straight  line  connecting  the  entrance  and  exit 
wounds  when  the  parts  have  resumed  the  position  of  the  body  at  the 
time  of  the  shooting.  The  new  bullet  is  seldom  deflected.  It  goes 
in  a  straight  line  from  the  point  of  impact  in  the  skin  to  the  point  of 
lodgment,  or  exit  from  the  body.  The  bullet  cuts  a  channel  through 
soft  parts,  like  muscle,  the  size  of  its  own  caliber  or  a  trifle  larger. 
The  cylindrical  track  and  the  surrounding  tissues  are  marked  by  the 
presence  of  hemorrhage,  contusion,  and  engorged  vessels.  Perfora- 
tions in  tendons  and  resistant  fasciae  are  marked  by  circular  or  slit -like 
openings.  When  projectiles  from  richochet,  or  extended  range,  lose 
their  balance,  tendons  may  be  torn  across  or  lacerated  as  a  result  of 
kej^holing. 

Foreign  Bodies  Carried  in  Wounds. — On  account  of  the  smaller 
frontage  of  the  new  military  rifle  bullet,  particles  of  clothing,  or  part 
of  the  equipment  of  soldiers  are  not  so  often  driven  in  wounds  as  they 
were  by  the  projectiles  of  the  larger  caliber  armament.     Our    ex- 


54  GUNSHOT   WOUNDS 

perience  in  Cuba  and  those  of  Makins,  Stevenson  and  others  in  recent 
wars  fully  confirm  this  statement.  The  old-time  larger  caliber  and 
lower-velocity  projectiles  carried  foreign  matter  in  wounds  that  proved 
a  fruitful  cause  of  prolonged  suffering  among  the  wounded.  Among 
the  particles  carried  in  with  the  balls  were  portions  of  cotton  and  wool 
clothing,  fragments  of  various  articles  found  in  the  field  kit  of  soldiers; 
also,  coins,  pieces  of  keys,  watches,  etc.,  carried  in  the  soldier's 
pockets.  Longmore  even  mentions  bits  of  leather  from  boots,  shoes, 
pouches,  etc.;  buttons,  nails  from  shoes,  buckles  and  other  metallic 
substances  which  have  from  time  to  time  been  extracted  from  body 
wounds  in  the  wars  of  the  past. 

Injury  to  Blood-vessels. — As  we  have  stated  elsewhere  injury  to 
blood-vessels  turns  out  to  be  one  of  the  chief  characteristic  lesions  of 
the  new  bullet.  The  projectile  cuts  the  side  of  a  vessel,  or  scoops  out 
a  hole  in  a  large  vessel,  like  a  cutting  instrument,  leaving  a  band  on  each 
side  of  the  openings.  The  cut  edges  are  not  lacerated  and  external 
hemorrhage  or  more  frequently  internal  hemorrhage  takes  place  at 
once.  In  the  body  cavities  the  hemorrhage  is  alarmingly  fatal.  In 
limbs  or  parts  where  the  vessel  is  well  supported  by  surrounding  tissue, 
aneurysm  is  apt  to  follow.  Vessels  are  no  longer  pushed  aside  as  they 
were  by  the  older  lower-velocity  bullets. 

Injury  to  Bone. — According  to  Fischer's  well-known  statistics  22 
per  cent,  of  all  gunshot  wounds  in  war  involve  fractures  of  the  long 
bones.  Although  his  statistics  were  gotten  out  before  the  advent  of 
the  new  armament  we  know  that  they  are  about  the  same  for  the  wars 
of  the  present.  A  study  of  the  effects  of  the  new  arm  on  the  diaphyses 
of  long  bones  of  the  extremities  confirms  entirely  the  work  of  the  experi- 
menters. The  Spanish- American,  South  African,  and  Russo-Japanese 
wars  have  given  abundant  evidence  of  the  destructive  effects  of  the 
small  bullet  on  the  compact  substance  of  the  long  bones.  These 
effects  are  magnified  at  short  ranges  or  when  the  velocity  is  high. 

In  our  experiments  referred  to,  we^  called  attention  to  perforations 
in  diaphyses  with  subperiosteal  fractures,  which  were  incomplete,  and 
to  the  great  necessity  of  handling  such  bone  lesions  with  care  in  order 
to  prevent  complete  solution  of  continuity.  Such  lesions  are  more 
often  seen  in  mid-range  shots.  This  condition  of  perforation  in  the 
compact  substance  of  a  long  bone  has  been  noted  in  recent  wars  and 
it  is  to  be  accounted  for  as  it  was  explained  in  the  dissecting  room  by 
us,  on  the  ground  that  bones  are  not  of  uniform  resistance,  the  bones 

^Annual  Report  Surgeon  General,  U.  S.  Armj^,  1893. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  55 

of  the  young  have  more  animal  matter  and  they  will  sustain  an  injury 
which  will  simulate  a  perforation,  while  the  bones  of  the  older  subjects 
have  more  mineral  matter  and  being  more  brittle,  they  will  show 
comminution  by  preference. 

Some  observers  have  expressed  surprise  that  extensive  comminu- 
tion should  take  place  in  the  latter  end  of  the  trajectory,  at  say  2000 
yards.  This  is  true  in  war  on  the  living  and  true  of  experi- 
mental shots  on  the  dead.  Up  to  350  yards  the  destructive 
effect  of  the  larger  caliber  lead  bullet  and  the  small-jacketed  bul- 
lets are  alike  severe.  Unless  guided  bj^  the  wound  of  entrance  or 
other  circumstances  it  is  difficult  within  this  range  to  determine  by 
the  appearance  of  the  external  wounds  alone  which  of  the  projectiles 
may  have  caused  the  injury.  Beyond  this  range  the  destructive 
effects  of  the  smaller  projectile  become  less  than  those  of  the 
larger  missile.  The  fissuring  is  less,  the  spiculae  of  bone  are 
larger,  and  they  are  more  apt  to  be  attached  to  the  perios- 
teum. These  differences  are  especially  noticeable  from  the  500 
to  the  1500  yard  ranges.  At  2000  yards  the  small  bullet  again  shows 
rather  extensive  comminution.  This  fact  has  been  noted  by  all 
observers,  and  it  has  been  variously  explained,  though  not  in  a  very 
satisfactory  manner.  It  has  been  said  that  the  projectile  has  lost  so 
much  of  its  velocity  of  translation  when  it  reaches  this  part  of  its  course 
that  it  is  apt  to  lodge,  and  that  the  velocity  of  rotation  causes  such  a 
disturbance  when  it  is  about  to  engage  that  comminution  is  the  result. 
The  angle  of  impact,  w^hich  is  rarely  perpendicular  at  this  range,  has 
also  been  brought  forth  as  a  possible  cause.  Certain  it  is  that  a  number 
of  the  projectiles  were  observed  at  this  range  by  us  to  impinge  side 
on  at  the  moment  of  impact.  The  results  in  recent  wars  tally  with 
those  observed  by  experimenters.  Exaggerated  destructive  effects 
have  been  reported  at  2000  yards  or  more,  and  they  are  most  likely  the 
effects  of  lateral  pressure  from  tangential  shots. 

Injury  to  the  Epiphyseal  Ends  of  Bones. — ^The  results  in  all  of  the 
recent  wars  give  convincing  evidence  of  clean  cut  perforation  with 
little  or  no  fracture  in  nearly  all  cases  of  injury  to  the  joint  ends 
of  bones.  This  is  due  to  the  fact  that  the  bone  in  the  epiphysis  is 
soft  and  offers  but  little  resistance,  compared  to  that  in  the  diaphysis. 
Unlike  the  lesion  in  the  diaphysis  the  extent  of  injury  is  uninfluenced 
by  velocity.  Even  close  shots  will  show  perforation,  in  the  head  of 
the  tibia  for  instance,  with  little  or  no  fragmentation.     Perforations 

LIBRARY  OP  THE 

ALUMN!  ASSOCIATION 

COLLEGE  OF  PHiSlCiAuB  a;^D  SUHGtU^^' 
COLUMBIA  UNIVERSUY 
I^RW  YORK 


56  GUNSHOT   WOUNDS 

are  not  confined  to  jacketed  bullets;  they  were  sometimes  seen  with 
the  use  of  the  larger  elongated  lead  bullets.  The  uniform  perforation 
of  the  epiphyses  of  bones  from  the  new  bullet  has  contributed  more 
than  any  of  the  characteristic  effects  of  the  new  armament  to  make 
the  wars  of  the  present  more  humane. 

Injuries  to  the  Head. — A  study  of  close  shots  in  the  living  such  as 
have  been  noted  repeatedly  from  suicides  shows  the  wounds  of  the  cran- 
ial vault  to  be  typical  of  the  class  known  under  the  name  of  Explosive 
Effects.  In  such  cases  extensive  fissures  radiate  toward  each  other 
from  the  points  of  entrance  and  exit;  fracture  of  the  base  through  the 
sphenoids  and  temporal  bones  are  not  uncommon,  and  instances  are 
described  in  which  the  skull-cap  and  the  skin  covering  it  have  been 
literally  torn  away.  The  observations  that  have  been  made  among 
the  dead  and  those  who  have  lived  to  reach  the  field  hospitals  in  recent 
wars  show  that  at  battle  ranges  even,  the  amount  of  comminution 
and  Assuring  of  the  bones  of  the  skull  is  great.  This  was  particularly 
so  among  those  we  saw  at  Santiago. 

EFFECTS  OF  THE  POINTED  BULLET  OR  BULLET  "  S  "  OF  THE 

GERMANS 

A  change  is  about  to  take  place  in  the  shape  and  weight  of  the  bul- 
lets of  the  military  rifles  for  all  armies  that  deserves  consideration  at 
this  time.  This  bullet  is  popular  with  military  men  because  it  has  a 
flatter  trajectory,  and  longer  danger  zone  than  any  of  the  reduced 
caliber  bullets  tried  so  far.  Such  a  bullet  has  recently  been  adopted 
by  England,  Germany,  Turkey  and  the  United  States.  The  one 
adopted  by  this  country  has  a  pointed  instead  of  an  ogival  head.  It  is 
1.08  inches  in  length;  .3083  inch  in  diameter;  weight  150  grains;  the 
jacket  is  composed  of  cupro-nickel  steel.  The  velocity  of  translation 
is  2700  f.s.  at  the  muzzle,  and  the  velocity  of  rotation  3240  turns  per 
second  as  it  issues  from  the  weapon.  The  point  blank  range  firing 
standing  is  718.6  yards.  The  center  of  gravity  of  this  bullet  is  dis- 
posed well  toward  its  base.  Experiments  which  we  have  made  on 
cadavers  demonstrate  that  the  bullet  is  poorly  balanced  and  that  the 
slightest  amount  of  resistance  will  cause  it  to  turn  on  its  short  axis. 
The  resistance  in  the  hip-joint,  the  chest,  and  abdominal  walls  caused 
the  bullet  to  turn  in  nearly  every  instance,  as  shown  by  keyholing  in 
the  head  of  barrels  of  sawdust  immediately  behind  the  target,  and  the 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


57 


resulting  wounds  were  comparable  to  those  inflicted  bj^  an  expanding 
bullet.     (See  Figs.  34  and  35.) 

Doebbelin^  reports  probably  the  first  case  of  a  wound  by  the  ''S" 
bullet,  which  corresponds  to  our  pointed  bullet,  in  a  soldier  who  was 
shot  twice  in  the  back,  by  a  sentinel  at  25  meters  distance,  as  he  was 
attempting  to  escape.  There  were  two  wounds  of  entrance  about  the 
size  of  a  lead  pencil.     The  first  was  located  opposite  the  tenth  rib 


Fig.  34. — Experimental  shot  in  cadaver.     Keyholing  of  pointed  bullet  in  blotting  paper  behind 
target  after  going  through  hip-joint  at  a  simulated  range  of  100  yards. 


near  the  right  axillary  line;  the  second  was  located  9  cm.  to  the  right 
of  the  base  of  the  coccyx.  The  wounds  of  exit  were  both  large.  The 
upper  being  about  the  size  of  a  fiftj^-cent  piece  on  the  line  of  the  right 
nipple,  shattering  the  eighth  rib,  making  a  cavity  at  the  point  of  frac- 
ture the  size  of  a  fist.  The  lung  was  uninjured.  Wound  of  exit 
contained  splinters  of  bone.  The  lower  wound  of  exit  was  the  size  of 
a  silver  dollar  containing  bone  splinters  and  a  fragment  of  the  bullet 
which  was  located  4  cm.  below  the  crest  of  the  right  ilium  near  the 
anterior  superior  spine.  After  opening  the  abdomen  the  diaphragm 
was  found  lacerated  from  its  attachment  to  the  anterior  wall  of  the 

1  Deutsche  Mil.  Aertztl.  Ztschr.,  Berlin,  1906,  XXXV,  625-628. 


58 


GUNSHOT   WOUNDS 


chest,  and  the  bullet  causing  the  upper  wound  had  plowed  through  the 
dome  of  the  liver  making  a  channel  15  cm.  long  and  5  cm.  in  diameter. 
The  intestines  were  not  injured.  A  tampon  was  placed  in  the  liver 
wound  and  the  abdomen  sewed  up,  leaving  a  drainage  tube.  The 
patient  was  discharged  from  hospital  on  the  eighteenth  day  cured. 
Fig.  36  shows  the  eflfects  of  the  U.  S.  Army  pointed  bullet  on  the 
femur  at  close  range. 


Fig.  35. — Explosive  effects  in  right  thigh  of  a  cadaver  due  to  pointed  bullet  shot  out  of  U.  S 
magazine  rifle  at  simulated  range  of  100  yards.  Entrance  wound  round,  size  of  bullet.  Exit 
wound  6  inches  long,  by  3  inches  wide;  opening  large  enough  to  admit  fist.  Bullet  hit  femur  in 
middle  third  causing  extensive  fragmentation  and  it  then  struck  head  of  barrel  behind  the  target, 
side  on.     A.  M.  School  collection. 


Hunters^  after  large  game  have  noticed  the  keyholing  of  the 
pointed  bullet  in  soft  and  resistant  parts  alike,  and  the  slashing 
effects  are  reported  to  be  great.     Col.  Roosevelt  in  his  African  Game 


^Stewart  Edward  White  and  Chas.  Newton  in  "Arms  and  the  Man,' 
1,1911. 


June 


CHAEACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  59 

Trails^  states  that  the  Winchester  405  and  Springfield  cal.  .  30  were 
the  weapons,  one  of  which  he  always  carried  in  his  hand,  and  he  adds 
''for  ordinary  game  I  much  preferred  them  to  any  other  rifles."  At 
289  and  again  at  180  yards,  the  full-jacketed  sharp-pointed  Springfield 
rifle  bullet  brought  down  two  Eland  bulls,  each  with  one  shot,  as  heavy 


Fig.  36. — Pvt.  E.  S.,  0.  A.  C,  U.  S.  A.,  a  prisoner,  attempted  escape  from  guard  at  Ft.  Wayne, 
Mich.,  May  17,  1909.  Shot  with  .30  cal.  Springfield  rifle  using  the  service  cartridge  of  1906  ammimi- 
tion,  pointed  bullet. 

On  entrance  to  hospital  patient  was  in  state  of  shock.  Wound  entrance  1  inch  to  right  and  1  inch 
above  aniis  size  lead  pencil.  Wound  exist  at  outer  border  of  right  thigh  just  below  great  trochanter 
3  inches  by  3  inches  in  diameter  and  greatly  lacerated,  fUled  with  broken  bone.  The  whole  hip 
presented  a  greatly  contused  aspect.  Further  examination  revealed  compound  comminuted  frac- 
ture of  right  femur  just  below  great  trochanter.  An  extensive  area  of  loose  bone  was  plainly 
palpable. 

Subsequent  history  of  case  marked  by  suppuration,  secondary  operation  for  necrosis,  and  3  1/2 
inches  shortening  -nith  complete  use  of  leg.     Exposure  made  in  1910. 

Reported  by  Major  D.  C.  Howard,  Med.  Corps,  U.  S.  Army. 

as  a  prize  steer,  the  bullet  making  "a  terrific  rending  compared  with 
the  heavier  ordinarj^  shaped  bullet  of  the  same  composition."  For 
heavy  game  like  rhinos  and  buffaloes  he  personally  preferred  a  double 
barreled  Holland  500-450.  An  examination  of  some  heads  of  hippos 
and  rhinos  in  the  new  National  ]\Iuseum  at  Washington  shows  remark- 
able crashing  effects  of  the  soft-nose  bullet  of  the  latter  rifle  against 

^African  Game  Trails  b}-  Theodore  Roosevelt,  pp.  141-142  and  190-191. 


60 


GUNSHOT   WOUNDS 


thick  resistant  bone.  Col.  Roosevelt^  again  informs  us  that  at  350 
long  paces  he  brought  down  a  hyena  "with  its  throat  cut,  the  little 
sharp-pointed  full-jacketed  bullet  makes  a  slashing  wound."  At 
360  yards  while  shooting  against  giraffe  he  states 
that  "the  sharp-pointed  bullet  penetrated  well  with- 
out splitting  into  fragments,  causing  a  rending  shock." 
The  same  reports  come  to  us  from  isolated  cases 
of  injury  upon  the  natives  by  the  new  pointed  bullet 
in  the  Philippines.  The  effects  of  the  pointed  bullet 
in  the  Turko-Balkan  War  of  1912-1913  have  sus- 
tained the  estimates  of  the  experimenters  as  to  its 
degree  of  deadliness.  The  body  wounds  in  the 
two  belhgerent  armies  seldom  lived  to  receive 
hospital  care.  The  high  ratio  of  wounds  by  shrapnel 
which  in  themselves  cause  an  excessive  mortality 
among  body  wounds  have  come  in  to  mask  the  dead- 
liness of  the  pointed  bullet,  but  the  reports  of  all  the 
observers  are  unanimous  on  the  field  mortality. 
Fig.  37.— Photo-  Major  P.  C.  Fauntleroy,  M.  C,  U.  S.  Army,  our 
graph  showing  Turkish  attache  with  the  armies  in  the  field  from  Jan.  1  to 

cartridge     and     bullet    -.  j-         ■,  ,  .  ,    . 

used  in  Turko-Balkan  March  15,  reports  the  approximate  total  casualties 
^^'■-  in  the  Bulgarian  Army  as  follows: 


Killed 

Wounded 

Died  from  wounds 

Officers 

Soldiers 

400 
23,000 

1,000 
55,000 

300 
10,000 

About  20  per  cent,  of  all  wounds  were  from  shrapnel. 

If  we  add  the  number  of  officers  and  men  killed  and  wounded,  we 
find  the  ratio  of  killed  to  wounded  to  be  1  to  2.5.  The  very  few 
abdominal  wounds  that  lived  to  reach  hospital  care  were  prone  to 
develop  localized  septic  peritonitis  with  abscess.  Penetrating  chest 
wounds  by  the  spitz-ball,  as  the  pointed  bullet  is  called  over  there, 
were  prone  to  the  development  of  complications  like  pneumo-hemo- 
thorax,  pyothorax,  etc.  Of  the  wounds  by  the  spitz-bullet  that  reached 
hospital  care,  the  majority  were  not  serious  and  recovery  occurred  in 


1  Op.  cit.,  pp.  197-198  (2),  205. 


CHARACTERISTIC    LESIONS    CAUSED   BY   PROJECTILES 


61 


from  four  to  six  T\'eeks.  ]\Iuch  to  the  surprise  of  the  observers  the 
pointed  bullet  often  lodged.  This  was  attributed  erroneously  to 
defective  ammunition. 

With  simulated  velocities  at  800  to  1000  yards  the  bullet  in  our 
experiments  already  referred  to  showed  great  tendency  to  lodge  upon 
striking  against  compact  and  cancellous  bone  tissue.  The  field  sur- 
geons in  the  Turko-Balkan  War  also  reported  its  lodgment  most  gen- 


FlG. 


38. — Skiagram  of  fractured  humerus  with  explosive  effects  by  Turkish  bullet  at  battle  of 
Lulu  Bergas,  400  meter  range. 


erally  at  800  to  1000  meters,  especially  when  resistant  bone  was  hit, 
and  they  saw  explosive  effects  at  short  ranges  when  resistant  structures 
were  traversed. 

It  requires  no  prophet  to  predict  that  the  war  wounds  of  the 
future  will  be  much  more  grave.  Body  wounds  will  be  more  uni- 
formly fatal;  injury  to  bone  will  be  more  extensive  and  prone  to  sup- 
puration. The  humane  character  of  the  reduced  caliber  bullet 
wounds  so  happily  noted  in  recent  wars  will  be  less  frequent.     This 


62 


GUNSHOT    WOUNDS 


will  be  especialty  true  of  wounds  of  the  lungs  and  epiphyseal  ends  of 
bones. 

The  following  skiograms  and  photographs  from  the  Turko-Balkan 
war  of  1912-13  were  presented  to  the  War  College  Library  by  Major 
P.  C.  Fauntleroy,  M.  C,  U.  S.  A.  (Figs.  38  to  47). 


Fig.  39. — Skiagram  showing  oblique  fracture  tibia  by  ricochet  Turkish  pointed  bullet.     Lodged 
bullet  was  removed  and  shows  to  left  of  skiagram. 

STOPPING  POWER  OF  PROJECTILES  FROM  RIFLES,  PISTOLS 

AND  REVOLVERS 

The  stopping  power  of  firearms  is  of  vital  importance  on  certain 
occasions.  The  sportsman  after  large  vicious  game  feels  more  secure 
when  he  encounters  an  animal  at  close  quarters  if  he  is  armed  with  a 
rifle  that  propels  a  missile  with  deadly  effect.     For  personal  encounters 


CHARACTERISTIC    LESIONS    CAUSED    BY    PROJECTILES 


63 


Fig.  40. — Skiagram  showing  a  partial 
butterfly  fracture  by  Turkish  bullet.  Lodged 
bullet  deformed. 


Fig.  41. — Skiagram   showing   a   lodged  unde- 
formed  Turkish  Spitz  bullet  under  skin. 


Fig.  42. — Skiagram   showing   a   Turkish   rifle 
bullet  lodged  in  left  knee-joint. 


Fig.   4.3.- 


-Skiagram   showing   a 
bullet  butt-end  to. 


lodged  Spitz 


64 


GUNSHOT   WOUNDS 


Fig.  44. — Skiagram  showing  a  lodged  Turkish  rifle  bullet. 


Fig.   45. — Skiagram  showing  Turkish  rifle  bullet  lodged  in  right  lung. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


65 


Fig.  46. — Skiagram  showing  lodged  ricochet  Turkish  bullet  from  battle  of  Tamrach. 


Fig.  47. — One  and  two  are  photographs  of  nucleus  and  envelope  of  lodged  missiles  in  Fig.  46. 


66  GUNSHOT   WOUNDS 

in  self  defense,  it  is  useless  to  carry  anything  but  an  effective  weapon. 
At  war  with  savage  tribes  or  a  fanatical  enemy,  a  military  man  seeks 
to  arm  his  soldiers  with  a  rifle  that  delivers  projectiles  with  telling  effect. 
A  fanatic  like  a  Moro  wielding  a  bolo  in  each  hand  who  advances  with 
leaps  and  bounds  and  who  never  knows  when  he  is  hit  until  he  is  shot 
down  must  be  hit  with  a  projectile  having  a  maximum  amount  of 
stopping  power.  Again,  the  military  man  has  to  reckon  upon  the 
stopping  power  of  projectiles  against  cavalry  and  artillery  horses  in 
a  charge. 

The  stopping  power  of  the  reduced  caliber  rifle  bullet  though  less 
than  that  of  its  predecessors  the  .45-caliber  Springfield,  Martini- 
Henry,  old  Mauser,  or  Gras,  is  still  considered  sufficient  for  all  the 
purposes  of  civilized  warfare.  At  least  it  proved  so  in  the  Spanish- 
American,  Boer,  Russo-Japanese  and  the  Turko-Balkan  wars.  Even 
the  stoical  Japanese  soldier  fell  back  as  a  rule  when  he  was  hit  the  first 
time.  Five  per  cent,  of  the  Japanese  wounded  were  never  admitted 
to  hospital.  They  were  treated  on  the  line,  but  we  are  not  told  that 
they  altogether  ignored  the  fact  of  being  wounded.  We  may  assume 
that  for  all  the  purposes  of  war  among  civilized  nations  the  present 
military  rifle  possesses  sufficient  stopping  power.  Major  Charles 
Lynch,  U.  S.  Army,  our  attache  with  the  Japanese  Army  in  his  report 
to  the  War  Department,  questions  the  stopping  power  of  the  Japanese 
bullet.  This  bullet  is  one  of  the  lightest  used  by  any  of  the  nations, 
being  6.50  millimeters  in  caliber,  11  1/2  grams  .in  weight.  He  states 
that  "a  man  hit  with  the  Japanese  bullet  will  come  on  when  it  has 
passed  through  his  body  anywhere,  except  at  a  vital  point."  The 
stopping  power  of  this  bullet  is  not  questioned  by  other  observers  but 
we  are  convinced  of  the  truth  of  Major  Lynch' s  statement  when  the 
weapon  7s  used  against  a  determined  enemy  or  a  savage  tribe. 
Col.  Stevenson  states  that  the  "medical  officers  who  served  in  the 
Wizirestan  Chitral  Expeditions  of  1895  where  Lee-Metford  rifles 
were  first  used  in  warfare,  and  Mr.  H.  C.  Thompson  who  wrote  the 
history  of  the  latter  campaign,  believe  that  the  English  small-bore 
then  in  use  could  not  be  depended  upon  to  stop  a  savage  or  determined 
man  in  a  charge.  ''Many  of  the  enemy  in  these  two  campaigns 
continued  to  advance  and  fight  after  the  receipt  of  from  one  to  six 
wounds  by  Lee-Metford  bullets."  These  bullets  were  only  effective 
upon  striking  vital  parts  or  parts  concerned  in  bodily  activity.  Our 
own  officers  have  repeatedly  reported  in  a  similar  way  against  the  ef- 
fectiveness of  the  Krag-Jorgensen  bullet  in  the  Philippine  Campaigns. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  67 

Colonel  Winter  and  Captain  McAndrew,  Medical  Corps,  U.  S.  A., 
have  related  the  following  incident  to  the  author  which  bears  upon  the 
failure  in  stopping  power  of  our  service  rifle:  In  1907  a  Moro  charged 
the  guard  at  Jolo,  P.  I.  When  he  was  within  100  yards,  the  entire 
guard  opened  fire  on  him.  When  he  had  reached  within  5  yards  of 
the  firing  party  he  stumbled  and  fell  and  while  in  the  prone  position 
a  trumpeter  killed  him  by  shooting  through  the  head  with  a  .  45-caliber 
Colt's  revolver.  There  were  ten  wounds  in  his  body  from  the  service 
rifie.  Three  of  the  wounds  were  located  in  the  chest,  one  in  the  ab- 
domen and  the  remainder  had  taken  effect  in  the  extremities.  There 
were  no  bones  broken. 

Sportsmen  after  large  game  in  the  Jungle  prefer  to  arm  themselves 
with  the  larger  cahbers.  On  account  of  the  superior  penetration  and 
extended  range  of  the  jacketed  bullets,  the  reduced  calibers  are  only 
preferred  in  the  open. 

Because  the  stopping  power  of  our  .38-caliber  Colt's  revolver  had 
failed  us  on  numerous  occasions  in  the  Philippines  and  elsewhere  the 
War  Department  constituted  a  Board  in  1904  composed  of  Col. 
John  T.  Thompson,  Ordnance  Department  and  the  writer,  as  the 
medical  member,  to  conduct  a  series  of  tests  with  bullets  of  different 
size,  weight  and  other  characteristics,  to  determine  upon  a  bullet  that 
should  have  the  stopping  power  and  shock  effect  at  short  ranges,  neces- 
sary for  a  pistol  in  the  military  service.  To  conduct  these  tests  the 
Ordnance  Department  furnished  the  Board  a  number  of  pistols  and 
revolvers  with  certain  ammunitions  as  follows: 

It  will  be  seen  by  the  table,  pages  70  and  71,  that  the  calibers  varied 
between  .476  inch,  the  greatest,  and  .3012  the  smallest,  which  cor- 
respond to  the  extremes  in  variation  in  military  pistols  so  far  as  was 
known  to  the  Board. 

Lead,  jacketed  and  metal  patch  or  soft -nose  bullets  were  used. 
To  produce  dum-dum  effects  the  points  of  some  of  the  jacketed  bullets 
were  filed  to  expose  the  lead. 

The  form  of  bullets  included  the  truncated  cone,  the  spherical  seg- 
ment, blunt  point,  hole  in  point,  cupped  point,  and  one  with  a  hole 
in  point  filled  by  a  copper  shell,  primed  and  charged  (explosive  bullet.) 

The  weights  of  bullets  varied  between  92 . 6  grains  and  288 . 1  grains. 

The  initial  velocities  varied  between  700  f.s.  and  1420  f.s. 

The  lowest  muzzle  energy  was  191  foot-pounds  and  the  highest 
was  415  foot-pounds.  The  revolvers  and  pistols  were  selected  for 
their  value  in  ballistic  elements  and  not  for  a  test  of  their  mechanism. 


68 


GUNSHOT   WOUNDS 


Revolvers  and  pistols  being  short-range  weapons,  75  yards  were 
agreed  upon  as  the  extreme  range,  37  1/2  yards  as  the  medium  range, 
and  near  the  muzzle  as  close  range.  Simulated  velocities  were  used 
for  the  first  two  ranges. 

The  Board  fired  altogether  into  ten  cadavers,  sixteen  beeves  and 
two  horses.     The  shock  on  cadavers  was  estimated  by  the  amount  of 


Fig.  48. — Antonio  Caspi  a  prisoner  on  the  Island  of  Samar,  P.  I.  Attempted  to  escape  Oct.  26, 
1905.  He  was  shot  four  times  at  close  range  in  a  hand-to-hand  encounter  by  a  .38  cal.  Colt's  re- 
volver loaded  with  U.  S.  Army  regulation  ammunition.  He  was  finally  stunned  by  a  blow  on  the 
forehead  from  the  butt-end  of  a  Springfield  carbine.  1.  Bullet  entered  chest  near  right  nipple, 
passed  upward,  backward  and  outward,  perforated  lung  and  escaped  through  back  passing  through 
edge  of  right  scapula.  2.  Bullet  entered  chest  near  left  nipple,  passed  upward,  backward  and  in- 
ward, perforated  lung  and  lodged  in  back  in  subcutaneous  tissues.  3.  Bullet  entered  chest  near  left 
shoulder,  passed  downward  and  backward,  perforated  lung  and  lodged  in  back.  4.  Bullet  entered 
palm  of  left  hand  and  passed  through  subcutaneous  tissues  and  escaped  through  wound  on  anterior 
surface  of  forearm.  Treated  at  military  hospital,  Borongan,  Samar.  Turned  over  to  civil  author- 
ities cured,  Nov.  23,  1905.     Reported  by  L.  P.  Lewald,  1st  Lieut.  Medical  Corps,  U.  S.  Army. 

disturbance  which  appeared   in  a  limb  when  the  body  was  suspended 
by  the  neck. 

We  found  that  the  amount  of  shock  as  measured  by  this  method 
was  always  proportional  to  (1)  the  sectional  area  of  the  bullet,  (2) 
to  the  resistance  which  the  bullet  encountered  on  impact,  and  (3) 
that  it  was  proportional  also  to  the  amount  of  tissue  destroyed. 
The  diaphyses  of  the  long  bones  showed  the  greatest  amount  of  resist- 
ance, and  consequently  the  greatest  amount  of  destruction,  and  the 
two  latter — viz.,  resistance  and  destruction  of  tissue,  which  are  so 


CHARACTERISTIC    LESIONS    CAUSED    BY    PROJECTILES  69 

intimately   associated   with   shock   effects — were   invariably   greater 
when  a  larger  caliber  bullet  was  used. 

In  attempting  to  define  shock  effects  or  stopping  power  in  living 
animals  we  had  to  consider  shots  against — 

1.  Vital  parts. 

2.  Non-vital  parts. 

3.  The  anatomy  necessary  to  locomotion  or  parts  essential  to 
activity. 

(a)  As  one  might  suppose,  all  shots  against  vital  parts  from  what- 
ever arm  showed  immediate  and  complete  stopping  power. 

(b)  For  shots  in  non-vital  parts  like  the  lungs,  liver,  intestines, 
etc.,  exclusive  of  large  vessels  the  shock  or  stopping  power  increased 
with  the  sectional  area  of  the  missile  and  it  was  notably  less  with  the 
smaller  sectional  area  projectiles  although  they  possessed  far  more 
energy. 

(c)  The  stopping  power  of  bullets  upon  colliding  against  parts 
necessary  to  locomotion  or  parts  essential  to  activity  was  considered 
positive  when  fracture  of  the  long  bones  occurred.  Measured  by  this 
standard  all  the  bullets  tried  possessed  sufficient  stopping  power  when 
for  instance  the  tibia  or  femur  was  fractured.  The  stopping  power  of 
the  larger  caliber  projectiles  was  considered  positive  in  gunshot 
wounds  of  the  epiphyseal  ends  of  bones  entering  into  the  formation 
of  the  ankle,  knee,  hip,  shoulder  and  elbow,  and  doubtful  when  these 
structures  were  traversed  by  the  small  .3012  caliber  jacketed  bullet 
of  the  Luger  pistol. 

In  those  cases  where  an  effort  was  made  to  increase  shock  effects 
and  destruction  of  tissue  by  the  use  of  metal  patch  or  marred  jacketed 
bullets,  these  expedients  failed  in  the  soft  parts  and  epiphyseal  ends  of 
bones,  because  the  resistance  in  these  tissues  was  not  enough  to  dis- 
integrate the  projectile,  or  in  any  way  to  increase  its  sectional  area. 

As  quick  firing  is  an  important  element  in  close  encounters,  we  made 
a  number  of  tests  to  demonstrate  what  would  be  the  stopping  power 
by  delivering  the  maximum  energy  of  different  projectiles  in  quick 
succession  at  close  quarters,  in  bodily  regions  like  the  chest  and 
abdomen  away  from  the  spine  and  large  vessels.  In  this  way  we  pur- 
posed to  see  how  many  shots  it  would  require  to  cause  an  animal  to 
drop  to  the  ground.  The  animals  selected  were  beeves  about  to  un- 
dergo slaughter  in  the  Chicago  stock-yards.  Each  animal  was  tied  to  a 
post,  and  at  the  conclusion  of  each  test,  which  occupied  but  a  few  sec- 
onds it  was  immediately  killed  in  the  usual  way  by  the  stock-yard 


70 


GUNSHOT   WOUNDS 


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CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


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72  GUNSHOT   WOUNDS 

force.  For  the  purpose  of  the  quick-firing  experiments  we  employed 
the  following  calibers:  .47.6,  45.5  and  .45  from  Colt's  revolvers;  the 
.38-cal.  Colt's  automatic  and  the  .3012  Luger  pistol  which  employed 
the  steel-clad  bullets.  All  of  the  bullets  used  in  the  experiments  lodged 
in  the  body  so  that  every  particle  of  energy  was  delivered  with  each 
bullet.  The  animals  invariably  dropped  to  the  ground  when  shot 
from  three  to  five  times  with  the  larger  caliber  Colt's  revolver  bullets, 
and  they  failed  in  every  instance  to  drop  when  as  many  as  ten  shots 
of  the  smaller  jacketed  bullets  from  the  Colt's  automatic  and  Luger 
pistol  bullets  had  been  delivered  against  the  lungs  or  abdomen.  This 
failure  on  the  part  of  the  automatic  pistols  of  small  caliber  set  at  rest 
at  once  the  claims  of  the  makers  to  the  effect  that  the  superior  energy 
and  velocity  of  their  weapons  was  a  controlling  factor  in  stopping 
power.  The  Board  was  of  the  opinion  that  a  bullet  which  will  have 
the  shock  effect  and  stopping  power  at  short  ranges  necessary  for  a 
military  pistol  or  revolver  should  have  a  caliber  not  less  than  .45. 
The  tests  showed  that  the  .47.6-caliber  lead  bullet  has  the  greatest 
stopping  power.  Its  weight  is  288.1  grains,  muzzle  velocity  729  f.s.; 
muzzle  energy  340  foot-pounds.  The  .45-caliber  lead  bullet  slightly 
blunt  point  was  next  in  stopping  power.  It  weighs  250  grains  with 
a  muzzle  velocity  of  720  f.s.  and  muzzle  energy  of  288  foot-pounds. 
A  slightly  blunt  point  has  the  advantage  of  making  a  bullet  bite  better 
in  striking  a  hard  bone  at  an  angle,  or  in  clipping  the  edge  of  a  vessel. 
All  things  considered  such  a  bullet  is  best  suited  for  the  military  service 
in  close  combat.  The  Board  considered  that  cup-pointed  bullets  such 
as  the  ''man  stopper"  might  be  issued  to  troops  fighting  savage  tribes, 
and  fanatics  in  the  brush  or  jungle.  This  bullet  showed  great  execu- 
tion on  live  animals.  It  weighs  218.5  grains.  It  has  a  muzzle  velocity 
of  801  f.s.  and  a  muzzle  energy  of  288  foot-pounds.  The  edge  of  the 
cup  readily  mushrooms  upon  striking  cartilage  and  joint  ends  of  bones, 
thereby  adding  to  the  sectional  area  and  stopping  power. 

None  of  the  full-jacketed  or  metal-patch  bullets  (all  of  which  were 
less  than  cal.  .  45)  showed  the  necessary  shock  effect  or  stopping  power 
for  a  service  weapon.  They  failed  especially  in  the  joint  ends  of  bones 
and  non-vital  parts  which  comprise  the  larger  part  of  the  target  area 
presented  by  the  human  or  animal  body.  In  the  event  that  an  auto- 
matic pistol  should  eventually  be  adopted  by  the  government  it  was 
recommended  that  the  caliber  should  not  be  less  than  .  45,  and  that  the 
point  of  the  jacket  should  be  made  very  thin  and  that  the  lead  core 
be  made  of  softer  lead  than  that  of  any  of  the  bullets  tested.     The 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


73 


object  of  this  was  to  invite  mushrooming.  We  were  well  aware  that 
this  recommendation  would  not  be  adopted  because  the  comity  of 
nations  frowns  upon  any  device  which  is  calculated  to  increase  the 
severity  of  wounds  in  war.  The  United  States  Government  has 
recently  adopted  the  .45  caliber  Colt's  automatic  pistol  which  uses  the 
steel-clad  bullet  without  features  to  invite  deformation. 


Fig.  49. — Fracture  of  femur  by  Colt's 
new  service  revolver  .476  cal.  at  simulated 
velocity  of  75  yards.  Army  Medical  School 
collection. 


Fig.  50. — Perforation  head  humerus  with 
slight  fracture  by  Colt's  new  service  revolver 
cal.  .476  at  range  of  37  1/2  yards.  Army 
Medical  School  collection. 


Shock  effects  depend  upon  the  sectional  area  of  a  bullet  and  the 
amount  of  energy  which  it  delivers  at  the  point  of  impact.  A  full- 
jacketed  bullet  which  makes  a  clean  fracture  in  bone,  and  then  leaves 
the  body,  takes  the  greater  part  of  its  energy  in  flight.  When  the  bone 
is  very  resistant  or  the  j  acket  is  marred,  the  bullet  may  disintegrate.  Its 
sectional  area  is  then  increased,  and  it  leaves  its  energy  in  the  body  in 
proportion  to  the  amount  of  metal  which  it  deposits  in  the  foyer  of 
fracture.  When  it  lodges  entirely,  it  parts  with  all  of  its  remaining 
energy.  In  comparing  skiagrams  showing  fracture  one  can  estimate 
wholly  or  in  part  the  amount  of  the  remaining  energy  or  shock  effects 


74 


GUNSHOT   WOUNDS 


in  a  given  case  by  the  amount  of  metal  which  is  deposited.  By  this 
standard  one  will  see  at  a  glance  the  striking  difference  which  is  nearly 
always  shown  between  a  bone  lesion  by  a  full-jacketed  bullet,  one  that 
is  but  partially  jacketed,  and  one  that  is  unjacketed  as  in  the  case  of 
a  lead  bullet.  Full-jacketed  projectiles  leave  but  few  metallic  par- 
ticles about  the  area  of  fracture  as  a  rule.  A  partially  jacketed  bullet, 
like  a  metal-patch,  or  a  bullet  with  nose  marred  purposely  or  other- 
wise,   will   leave   numerous   fragments,    some  of  them  much   darker 


Fig.  51. — Fracture  of  humerus  by  Colt's 
new  service  revolver  .45  cal.  Bullet  with 
blunt  point,  close  range.  Army  ^Medical 
School  collection. 


Fig.  52. — Fracture  of  femur  Colt's  new 
service  revolver  .45  cal.  carrying  a  bullet  with 
hole  in  point  close  range.  Army  Medical 
School  collection. 


than  others.  Those  that  are  darker  or  black  represent  part  of  the 
lead  core,  while  the  fragments  of  lighter  shade  represent  part  of  the 
envelope.  The  presence  of  dark  fragments  alone  indicates  the  result 
of  a  lesion  by  an  ordinary  unjacketed  lead  bullet  or  a  shrapnel  ball, 
and  more  often  the  latter  if  the  case  is  one  from  the  very  recent  wars 
in  which  shrapnel  balls  are  so  frequently  used. 

The  following  skiagrams  exhibit  bone   lesions  in  cadavers  when 
fired  into  with  projectiles  from  pistols  and  revolvers  (see  Table  No.  3). 


CHAKACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


75 


Fig.   53. — Man-stopper  bullets  from  Colt's  new  service  revolver  cal.    455  lodged  against  tibia  and 
femur  without  fracture.     Remaining  velocity  at  75  yards.     Army  Medical  School  collection. 


76 


GUNSHOT   WOUNDS 


The  X-ray  work  was  done  by  Professor  A.  Hewson  and  Doctor  W.  M. 
Sweet,  of  Philadelphia  (Figs.  49  to  68). 

We  are  not  acquainted  with  any  bullet  fired  from  a  hand  weapon 
that  will  stop  a  determined  enemy  when  the  projectile  traverses  soft 
parts  alone.  The  requirements  of  such  a  bullet  would  need  to  have  a 
sectional  area  like  that  of  a  3-inch  solid  shot  the  recoil  from  which 
when  used  in  hand  weapons  would  be  prohibitive. 

Finally  the  Board  reached  the  conclusion  that  the  only  safeguard  at 
close  encounters  is  a  well-directed  rapid  fire  from  nothing  less  than  a 


Fig.  54. — Fracture  of  tibia  from  man-stopper  bullet  fired  from  Colt's  revolver  new  service  cal. 
.455,  velocity  704  f.s.  Bullet  fragmented  and  lodged  just  under  skin.  Army  Medical  School 
collection. 


.45-caliber  weapon.  With  this  end  in  view  soldiers  should  be  drilled 
to  fire  at  moving  targets  until  they  have  attained  proficiency  as  marks- 
men. 

The  pointed  bullet  recently  adopted  for  the  military  rifle  by  the 
United  States,  Germany,  and  England,  will  no  doubt  exhibit  greater 
stopping  power  than  its  predecessors  which,  as  we  have  already  shown, 
has  hitherto  failed  entirely  in  encounters  with  savage  tribes. 


CHARACTERISTIC    LESIONS    CAUSED   BY   PROJECTILES 


77 


Fig.  55. — Fracture  of  femur  by  Colt's  new  service  revolver,  carrying  man-stopper  bullet, 
caliber  .455  with  simulated  velocity  at  37  1/2  yards.  Note  butterfly  character  of  fracture.  Army 
Medical  School  collection. 


78 


GUNSHOT   WOUNDS 


Fig.  56. — Perforation  by  marred  bullet  from  Colt's  automatic  pistol  .38  cal.  The  jacket 
was  not  ruptured  on  impact.  Range  5  yards  velocity  1107  f.s.  Army  MedicalSchool  collec- 
tion. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


79 


Fig.  57. — Perforation  neck  femur  by  soft  nose  or  metal  patch  bullet  from  Colt's  automatic  pisto 
.38  cal.  at  5  yards.     Army  Medical  School  collection. 


80 


GUNSHOT    WOUNDS 


Fig.  58. — Perforation  head  femur  by  the  9  mm.  Luger  pistol-jacketed  bullet  remaining  velocity  at 
37  1/2  yards.     Army  Medical  School  collection. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


81 


Fig.  59.  Fig.  60. 

Fig.  59. — Fracture  of  tibia  by  Colt's  automatic  pistol  .38  cal.,  full-jacketed  bullet,  remaining 
Metallic  fragments  are  few  in  number  and  very  small.     Army  Medical 


velocity  at  37  1/2  yards 
School  collection 

Fig.  60. — Fracture    by    Colt's 
Army  Medical  School  collection. 


automatic   pistol  .38    cal.,  full-jacketed    bullet    close   range. 


82 


GUNSHOT   WOUNDS 


Fig. 


61. — Fracture  from  soft  nose  bullet,  Colt's  automatic  pistol  .38  cal.  at  5  yards.     Army  Med- 
ical School  collection. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


83 


Fig.   62. — Fracture  from  soft  nose  bullet,  Colt's  automatic  pistol  .38  oal.  at  5  yards.     Army^Med- 

ical  School  collection. 


84 


GUNSHOT   WOUNDS 


Fig.  63. — Fracture  of  so-called  man-stopper  bullet  from  Colt's  .455  caliber  new  service  revolver 
at  5  yards.     Army  Medical  School  collection. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


85 


Fig.  64. — Butterfly  fracture  by  Colt's  automatic  pistol  bullet  .38  cal.,  at  close  range.     Jacket  of 
bullet  was  marred  by  filing  the  point  of  projectile. 


86 


GUNSHOT   WOUNDS 


Fig.  65. — Fracture  from  Colt's  new  service  revolver  unjacketed  bullet  .38  cal.  at  25  yards.      Army 

Medical  School  collection. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


87 


Fig.   66. — Fracture  with  butterfly  arrangement  of  fragments  from  Colt's  new  service  revolver,  un- 
jacketed  bullet,  at  74  yards.     Army  Medical  School  collection. 


88 


GUNSHOT   WOUNDS 


Fig.  67. — Fracture  from  Colt's  new  service  revolver,  unjacketed  bullet,  .38  cal.  at  5  yards.     Army 

Medical  School  collection. 


CHARACTERISTIC   LESIONS    CAUSED   BY   PROJECTILES 


89 


Fig.  68. — Fracture  by  soft  nose  bullet,  Colt's  automatic  pistol  Cal.  .38  at  5  yards.     Note  lodge- 
ment of  lead   nucleus,  fragmented.     Army  Medical  School  collection. 


90  GUNSHOT   WOUNDS 

Explosive  effects  in  gunshot  wounds  at  proximal  ranges  by  the  high- 
power  rifles  were  referred  to  in  the  beginning  of  this  Chapter,  p. 
36.  They  were  noted  by  all  experimenters  upon  cadavers  and 
animals,  and  there  is  record  of  their  appearance  in  war,  especially 
in  the  Manchurian  campaign.  Generally  speaking,  these  highly  de- 
structive effects  are  commonly  seen  when  using  the  older  rifles  like  the 
.45-caliber  Springfield  and  the  Martini-Henrj^  of  the  English  Army 
up  to  350  yards,  and  -^dth  the  rifles  of  reduced  caliber  the  character- 
istic effects  have  been  noted  still  farther. 

The  term  "Explosive  Effects"  is  in  a  measure  confusing  because  it 
conveys  the  impression  that  the  wound  is  the  result  of  an  explosion, 
or  explosive  bullet.  The  term  is  entirely  descriptive  and  it  owes  its 
origin  to  the  similarity  in  the  appearance  of  a  wound  caused  by  an 
explosive  ball  jjer  se,  as  compared  to  a  bullet  having  sufficient  velocity' 
and  energy  to  show  a  corresponding  lesion,  when  a  proper  impact  is 
made,  as  for  instance,  against  resistant  bone.  As  a  rule  the  entrance 
wound  presents  no  special  features.  In  a  few  instances  it  may  contain 
bony  sand.  When  a  resistant  bone  has  been  hit  the  area  of  fracture 
shows  loss  of  substance,  the  bone  ^\^ll  have  been  finely  comminuted, 
the  pulvarized  bone  ^^^ll  appear  not  only  in  the  line  of  flight  of  the  bul- 
let but  in  all  directions,  viz.,  at  right  angles  to  the  channel  and  back- 
ward into  the  wound  of  entrance.  Pulpification  of  the  tissues  will  be 
noted  along  the  parts  adjacent  to  the  channel  made  by  the  bullet  and 
for  some  distance  beyond.  The  exit  wound  is  large  and  lacerated  with 
the  appearance  of  an  explosion  having  occurred  from  within.  Torn 
muscles,  tendons,  and  at  times  lacerated  nerves,  mingled  with  pieces 
of  bone,  protrude  from  the  injured  parts.  The  channel  from  the 
wound  of  exit  is  funnel-shaped  with  the  base  of  the  funnel  correspond- 
ing to  the  exit  wound  and  the  apex  at  the  seat  of  fracture. 

Bony  structures  are  not  alone  in  showing  these  marked  lesions  with 
high  velocities.  Some  observers  have  noted  explosive  effects  up  to 
500  yards  with  the  reduced  caliber  bullet  in  "very  vascular  tissues, 
cavities  filled  with  liquid,  semi-liquid  or  viscous  masses,  such  as  the 
heart,  skull,  stomach,  intestines,  etc.  Fig.  104  shows  the  effects 
of  a  proximal  shot  on  the  skull  of  a  soldier  who  was  endeavor- 
ing to  escape  from  the  guard  at  Fort  Sheridan.  The  lesion  is  typical 
of  explosive  effects  so-called  and  in  our  experience  it  does  not  differ 
from  proximal  shots  on  cadavers.  For  other  evidences  of  explosive 
effects  on  the  head  see  Figs.  101,  102  and  105. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  91 

We  had  never  seen  a  wound  caused  bj-  an  explosive  bullet,  and  in 
order  to  compare  the  lesion  in  such  a  wound  with  the  explosive  effects 
of  bullets  we  fired  into  a  horse's  thigh  while  experimenting  for  the 
stopping  power  of  bullets  at  Chicago.  The  bone  lesion  observed  was 
not  different  in  our  experience  from  the  lesion  frequently  described 
under  the  term  explosive  effects. 

All  writers  on  the  subject  have  sought  to  explain  the  so-called 
explosive  effects,  but  it  remained  for  Col.  Stevenson  in  his  book 
''Wounds  in  War,"  to  give  us  a  comprehensive  description  of  the 
theoretical  and  true  explanation  of  these  interesting  lesions.  He 
takes  up  the  subject  under  the  following  headings: 

1.  The  theory  of  compressed  air. 

2.  The  theory  of  hj^draulic  pressure. 

3.  The  theor}"  of  rotation  of  the  bullet. 

4.  The  theory  of  deformation  of  the  bullet. 

5.  The  theory  of  heating  of  the  bullet. 

At  the  onset  we  may  state  that  none  of  the  theories  referred  to 
comes  up  for  serious  consideration.  They  are  merely  mentioned  to 
explain  the  confusion  that  once  obtained  in  interpreting  the  mechanics 
of  projectiles. 

1.  Theory  of  Compressed  Air. — This  is  among  the  oldest  of  the 
theories  to  explain  explosive  effects.  The  advocates  of  this  theory 
believed  that  the  projectile  massed  a  cushion  of  compressed  air  on  its 
head,  and  that  on  impact  this  compressed  air  again  expanded,  with 
more  or  less  violence,  not  unlike  the  expansive  force  of  an  explosive, 
thereby  causing  the  appearances  of  internal  pressure  which  are  noted 
in  wounds  showing  explosive  effects.  There  is  no  evidence  of  air 
having  been  forced  into  the  tissues  and  we  know  also  that  air  is  ex- 
tremely mobile  and  that  it  can  only  be  compressed  when  imprisoned 
under  great  pressure. 

2.  Hydraulic  Pressure. — This  theory  came  into  prominence  because 
water  when  fired  into,  offers  great  resistance  to  the  passage  of  a  bullet. 
The  act  of  firing  into  cans  of  water  that  are  sealed  or  unsealed  ex- 
hibits the  effects  of  a  powerful  internal  pressure.  The  hydraulic  theory 
can  only  be  employed  to  explain  destructive  effects  in  tissues  where  an 
organ  like  the  stomach,  or  urinary  bladder  is  filled  with  fluid  at  the 
moment  of  impact.  In  such  a  case  the  explosive  effects  simulate 
those  seen  in  the  case  of  a  femur  as  far  as  lacerations  and  contusions 
are  concerned.  In  reckoning  upon  the  subject  of  explosive  effects 
one  must  always  bear  in  mind  that  explosive  effects  are  proportional 


92 


GUNSHOT    WOUNDS 


to  (1)  the  velocity,  (2)  sectional  area,  (3)  deformation  and  (4)  to  the 
resistance,  on  impact.  Concerning  the  latter  we  may  add  that  there 
are  two  things  in  the  human  body  that  offer  a  maximum  of  resistance, 
viz.,  compact  bone  and  water.  In  order  to  exhibit  its  maximum  resist- 
ance the  water  has  to  be  in  the  form  of  a  fluid  or  a  semi-fluid  mass 
contained  in  a  cavity. 

The  velocity  of  rotation  as  a  cause  of  explosive  effects  needs  but 
a  passing  notice.     As  we  have  already  shown,  the  velocity  of  rotation 


Fig.  69. 


Fig.   70. 


Fig.  71. 


Fig.  72. 


Fig.   73.  Fig.  74. 

Fig.   69. — Shows  orifice  of  entrance  in  an  empty  tin  at  10  ft.  by  the  Karg-Jorgensen  bullet. 
Fig.  70. — Shows  orifice  of  exit  in  same  vessel. 
Fig.   71. — Shows  orifice  of  entrance  in  a  tin  filled  with  marbles. 

Fig.  72. — Shows   orifice   of   exit   in  the  same  vessel.     Note  the  impression  of  marbles  on  sides 
of  tin  caused   by   lateral    pressure. 

Fig.   73. — Orifice  of  entrance  in  a  tin  sealed  and  filled  with  water. 
Fig.  74. — Orifice  of  exit  in  the  same  vessel. 


of  the  reduced  caliber  bullet  with  ogival  head  makes  2400  turns  per 
second  at  the  muzzle,  and  the  pointed  bullet  adopted  by  our  army  and 
that  of  Germany  and  England  on  account  of  added  velocity  makes 
3240  turns.  The  velocity  of  rotation  does  not  diminish  as  rapidly  as 
the  velocity  of  translation,  that  is,  it  is  better  maintained  even  to 
the  latter  end  of  the  protectory.  The  rotation  of  the  small  bullet  is 
given  to  it  by  a  shorter  twist  in  the  rifling,  or  one  complete  turn  in  10 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  93 

inches.  If  a  bullet  makes  a  turn  on  its  long  axis  in  10  inches  of  its 
flight  when  traversing  the  femur  for  instance — the  latter  being  about 
1  inch  in  diameter — the  amount  of  turning  which  it  would  do  while 
fracturing  the  femur  would  about  equal  one-tenth  of  a  turn,  and  it  is 
not  likely  that  this  amount  of  rotation  could  in  any  waj^  be  responsible 
for  the  enormous  effects  noted  in  such  cases. 

As  to  the  theory  of  heating  to  explain  explosive  effects,  our  experi- 
ments quoted  elsewhere  have  demonstrated  conclusively  that  a  pro- 
jectile does  not  become  sufficiently  heated  by  the  act  of  firing  to 
destroy  microorganisms  placed  upon  it.  This  being  the  case,  the 
theory  is,  to  say  the  least,  not  tenable. 

While  we  were  experimenting  with  the  new  bullet  some  j-ears  ago 
we  repeated  many  of  the  experiments  of  von  Coler  and  others  to  show 
so-called  explosive  ejffects  by  firing  into  empty  tins,  tins  filled  with 
water,  sealed  and  unsealed;  tins  filled  with  wet  and  dr}^  sawdust,  also 
tins  filled  with  starch-paste  and  marbles.     (See  Figs.  69  to  74.) 

The  True  Cause  of  Explosive  Effects. — If  we  bear  in  mind  the 
factors  necessary  to  produce  explosive  effects — namely,  velocity, 
sectional  area,  deformation,  and  resistance  on  impact — we  have  to 
recall  the  fact  that  all  these  factors  have  abided  with  us,  except  the  high 
velocities,  since  the  early  history  of  firearms.  The  latter  appeared 
with  the  perfection  of  the  mihtary  rifle.  Of  the  factors  mentioned, 
which  relate  to  the  projectile,  velocity  is  the  most  potent  and  next  in 
order  come  sectional  area  and  deformation.  The  velocity  of  the  old 
Springfield  rifle  bullet  was  1300  f.s.  and  that  of  our  present  rifle  bullet 
is  2700  f.s.  The  energy  of  the  Springfield  bullet  was  1879  foot-pounds 
while  the  energy  of  the  U.  S.  magazine  rifle  (now  called  the  New  Spring- 
field rifle)  bullet  is  2400  foot-pounds.  Although  the  velocity  has  been 
doubled  we  find  that  the  energy  has  not  been  increased  correspond- 
ingly. This  is  due  to  the  diminution  of  the  sectional  area  and  weight  of 
the  smaller  bullet.  The  weight  of  the  bullet  was  reduced  in  the  change 
mentioned  from  500  to  152  grains,  while  the  velocity  was  doubled. 
The  152  grains  jacketed  bullet  impressed  with  a  remaining  velocity 
of  1300  f.s.,  which  was  the  maximum  velocity  of  the  Springfield's 
500-grain  bullet,  shows  no  explosive  effects.  If  it  travels  at  its  maxi- 
mum speed  2700  f.s.  or  thereabouts,  it  causes  enormous  destructive 
effects  so  that  we  must  attribute  its  power  to  destroy  tissues  to  its 
superior  velocity.  When  the  two  guns  mentioned  are  shot  side  by  side, 
at  similar  ranges,  into  parts  offering  the  same  resistance,  it  is  found 
that  the  explosive  effects  of  the  two  bullets  are  the  same  for  the  proxi- 


94  GUNSHOT   WOUNDS 

mal  ranges  up  to  about  350  yards,  and  they  continue  to  be  equally 
severe  with  the  smaller  bullet  up  to  500  yards.  On  the  skull  of  cadavers 
with  brain  and  scalp  in  situ  we  have  noted  all  the  appearances  of  ex- 
plosive effects  as  far  as  900  yards. 

If  one  will  examine  the  foyer  of  fracture  and  the  funnel-shaped 
channel  leading  to  the  wound  of  exit  as  a  result  of  a  gunshot  injury 
by  the  heavier  lead  bullet  at  proximal  ranges,  he  will  find  pieces  of 
the  disintegrated  lead  from  the  bullet,  and  bone  particles,  dispersed 
in  all  directions  as  already  explained.  It  is  most  evident  from  a 
study  of  the  force  which  caused  these  particles  to  penetrate  the 
tissues,  that  they  were  made  to  act  as  secondary  projectiles  by 
some  of  the  energy  of  the  bullet,  which  was  transferred  to  them  at 
the  moment  of  impact.  In  cavities  containing  fluid  contents,  the 
fluids  are  dispersed  and  part  of  the  energy  of  the  bullet  is  trans- 
ferred to  particles  of  water  or  fluid  masses,  and  they  in  turn  are 
propelled  from  their  original  positions  to  act  as  secondary  pro- 
jectiles. The  true  cause  of  explosive  effects  may  be  said  then  to  be 
the  transfer  of  energy  from  the  bullet  to  particles  of  its  own  composi- 
tion when  it  disintegrates,  as  well  as  to  spiculse  of  bone,  or  particles 
of  fluid,  or  soft  tissues.  The  amount  of  destruction  is  measured  by 
the  degree  of  energy  inherent  in  the  bullet,  and  we  should  add  that 
the  latter  depends  upon  the  velocity  which  the  projectile  possesses 
at  the  time  of  impact.  Sectional  area  and  deformation  of  the  pro- 
jectile favor  destruction  of  tissue,  but  they  are  not  essential,  since  small 
jacketed  bullets  that  show  no  deformation  upon  colliding  with  resist- 
ant bone  at  close  range  exhibit  explosive  effects  bearing  close  similar- 
ity to  those  instances  when  the  envelopes  and  core  of  the  bullet  un- 
dergo fragmentation. 

WOUNDS  BY  PROJECTILES  FROM  THE  ARTILLERY  ARM 

These  will  include  wounds  by  shells,  shell-fragments  and  shrapnel. 

Shell  Wounds. — Injuries  from  shells  are  more  often  inflicted  by 
fragments  of  shells  after  bursting.  They  vary  in  accordance  with  the 
size  and  irregularity  of  the  fragment.  They  are  always  lacerated  and 
contused.  Wounds  of  the  limbs  especially,  bear  great  similarity  to 
those  seen  in  civil  practice,  from  machinery  or  railroad  accidents. 
Lodgment  of  missiles  is  often  noted  because  the  velocity  of  the  pieces 
of  an  exploded  shell  is  low.  When  a  whole  shell  hits  at  a  high  rate 
of  velocity,  it  carries  everything  before  it.     When  striking  the  body 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  95 

of  an  individual,  a  large  opening  will  be  made  corresponding  to  the 
size  of  the  projectiles,  and  viscera  adjoining  the  point  of  impact  are 
dislodged  and  scattered.  Longmore  states  that  in  the  case  of  a  limb 
which  has  been  carried  away  by  a  shell  or  solid  shot  "the  end  which 
remains  attached  to  the  body  presents  a  stump  with  a  nearly  level  sur- 
face of  darkly  contused,  ragged,  but  still  connected  tissues,  deeply 
imbued  with  blood.  The  flesh  presents  an  aspect  of  having  been  torn 
asunder,  by  a  sudden  irresistible  force.  The  skin  and  muscles  do 
not  retract,  as  they  would  do,  had  they  been  divided  by  incision. 
Particles  of  bone  will  be  found  among  the  soft  tissues  on  one  side  of 
the  wound,  but  the  portion  of  the  shaft  of  the  bone  remaining  in  situ 
will  probably  be  found  unsplintered  and  without  long  projecting  jags 
or  points."  When  the  velocity  of  the  large  projectile  is  low,  the  in- 
jury is  quite  similar,  only  it  is  attended  with  more  laceration  and  a 
ragged  condition  of  the  skin.  The  surface  of  the  wound  is  not  so 
even.  The  bone  of  a  limb  exhibits  larger  spiculse  with  greater  tendency 
to  fissuring  in  the  part  of  the  bone  remaining.  There  is  more  extra- 
vasated  blood,  and  contusion  of  the  soft  parts  is  more  apparent.  In 
the  case  of  a  spent  shell  or  shot  there  may  or  may  not  be  external 
evidence  of  injury,  but  there  will  be  evidence  of  extensive  disorgani- 
zation in  the  way  of  contusion,  laceration,  crushing  of  soft  parts,  with 
or  without  bone  lesion. 

In  the  Civil  War  out  of  245,790  gunshot  wounds  359  were  reported 
due  to  solid  shot,  and  12,  520  to  shell  fragments.  Since  shells  are  now 
used  to  the  exclusion  of  solid  shot,  wounds  from  the  latter  are  no 
longer  seen  in  modern  wars.  Shells  are  more  especially  used 
against  material  and  wounds  from  this  projectile  or  its  fragments 
will  not  occur  very  frequently,  except  in  siege  operations  and  in  naval 
combats.  Shell  wounds  in  the  Spanish-American  war  aggregated 
7  1/2  per  cent,  of  all  wounds,  but  these  were  mostly  from  shrapnel 
balls.  Although  there  are  no  definite  figures  yet  available  for  this  class 
of  wounds  in  the  South  African  War,  it  is  safe  to  predict  that  the  latter 
figure  will  hardly  be  exceeded.  Makins  reports  that  shell  wounds  from 
shell  fragments  formed  but  a  small  proportion  of  the  injuries  treated 
in  hospitals  in  the  latter  war.  His  reference  to  this  class  of  wounds 
is  not  hopeful.  He  states  that  "the  features  presented  were  those 
of  lacerated  wounds,  while  the  more  severe  of  the  cases  which  survived 
only  offered  scope  for  operations  of  the  mutilating  class,  so  uncongenial 
to  modern  surgical  instincts."  Makins  also  states  that  in  some  cases 
the  impact  was  made  by  the  flat  surface  of  a  fragment  from  which  there 


96  GUNSHOT   WOUNDS 

was  no  visible  sign  of  injury.  In  one  case  of  this  kind  the  blow  was 
delivered  upon  the  epigastrium  of  a  soldier  and  it  was  followed  by 
vomiting  of  a  considerable  quantity  of  blood. 

Wind  Contusion. — The  case  just  referred  to  by  Makins  would  have 
been  called  a  wind  contusion  by  the  older  writers  on  gunshot  wounds. 
When  solid  shot  and  shell  were  more  often  employed  in  battle,  sur- 
geons often  saw  cases  of  extensive  internal  injury  to  the  viscera,  disor- 
ganization of  soft  parts,  and  even  fracture  of  bone  with  no  visible 
evidence  of  injury  to  the  surface.  Such  cases  were  attributed  to  the 
rapid  displacement  of  the  air  in  the  vicinity  of  the  injured,  and  the 
subsequent  shock  from  refilling  of  the  vacuum  thus  caused.  But  in- 
telligent men  like  Longmore  and  Baron  Larrey  soon  learned  that  the 
lesion  in  so-called  wind  contusion  was  the  result  of  pressure  of  heavy 
projectiles  having  slow  momentum,  against  a  tough  elastic  skin.  In 
such  cases  Longmore  believes  that  the  blow  is  delivered  obliquely  and 
that  as  the  elastic  skin  yields,  the  more  resistant  structures  beneath 
are  crushed  and  disorganized.  There  is  nothing  in  our  knowledge  in 
the  way  of  air  displacement  that  will  cause  lesions  marked  by  the  dis- 
organization mentioned  except  the  sudden  liberation  of  the  gases  of 
the  high  explosives,  and  in  these  cases  there  is  always  tearing  of  the 
skin  with  other  traumata. 

The  statistics  of  injuries  by  shells  and  shell  fragments  in  the  Man- 
churian  campaign,  like  those  in  the  Spanish-Amerian  war,  are  not  relia- 
ble for  the  reason  that  "in  the  field  nearly  all  wounds  classified  as 
Shell  Wounds  were  caused  by  Shrapnel"  (Lynch).  Follenfant^  states 
that  wounds  by  shells  charged  with  chimose  powder  were  very  different 
to  those  made  by  Shrapnell.  The  envelope  of  these  chimosed  shells 
was  reduced  to  small  particles,  like  scales,  or  cubical  in  shape,  with 
sharp  sides  and  angles  which  were  apt  to  tattoo  the  wounded  like  so 
many  grains  of  salt.  The  mental  shock  caused  by  the  explosion  and 
the  resulting  wounds  brought  on  nervous  symptoms,  especially  in 
officers,  like  neurasthenia  or  traumatic  hysteria.  These  nervous  symp- 
toms were  also  attributed  by  some  observers  to  poisoning  from  the 
gas  of  explosion,  which  was  absorbed  from  the  small  fragments,  lodged 
in  the  cellular  tissues. 

For  a  complete  description  of  the  effects  of  large  projectiles  in 
modern  war  we  have  to  turn  to  the  labors  of  our  naval  confreres. 
Surgeon  General  Charles  F.  Stokes,  U.  S.  Navy-,  calls  attention  to  the 

1  Archives  de  Medicine  et  de  Parmacie  Militaries  No.  48,  1906.  By  M.  Follen- 
fant,  French  Army. 

^  Proceedings  of  New  York  State  Medical  Society  for  1912. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  97 

probable  casualties  and  deadly  results  in  future  wars  between  modern 
battleships.  The  new  14-inch  guns  on  board  have  an  effective  range 
of  14  miles  and  they  can  fire  ^\ath  accuracy  on  moving  targets  at  7  to  9 
miles  with  amazing  rapidity.  Each  of  the  guns  fires  a  projectile  weigh- 
ing 1400  pounds  at  a  velocity  of  2900  f.s.  The  powder  charge  of  a  14- 
inch  piece  weighs  350-400  pounds  and  in  addition  it  carries  a  bursting 
charge  that  invites  extensive  fragmentation  of  the  projectile  on  impact. 
Both  the  propelling  and  bursting  charges  are  largely  composed  of  the 
modern  high  explosives  which  yield  poisonous  gases  like  CO,  and  NO2, 
as  products  of  combustion.  Indeed  one  of  the  chief  menaces  in  naval 
warfare  to-day  will  be  poisoning  from  powder  gases  arising  from  the 
bursting  shells  of  the  enemy  and  the  batteries  on  board  each  ship. 
As  pointed  out  by  General  Stokes  there  ^dll  be  two  types  of  poisoning 
— ''one  resembling  illuminating  gas  poisoning,  the  other  irritative  in 
its  effects.  Both  may  vary  in  degree.  In  the  one  group,  in  mild 
cases,  we  find  dilatation  of  the  pupil,  impaired  vision,  a  fall  in  blood 
pressure,  a  rapid  heart  action  and  possibly  some  mental  confusion." 
Slighter  degrees  of  poisoning  will  doubtless  impair  the  effectiveness  of 
the  men,  and  larger  dosage  will  cause  them  to  succumb  into  unconscious- 
ness and  death.  The  best  account  in  our  literature  on  the  effects  of 
modern  naval  armament  in  recent  wars  is  found  in  the  Japanese 
Government  Report  by  Saneyoshi  and  Suzuki^  on  the  casualties  of 
the  naval  combats  in  the  Chino-Japanese  War  in  1894-95.  Aboard 
ship  the  character  of  wounds  from  shells  and  shell  fragments  hitting 
the  vicinity  of  the  men  differs  materially  from  that  seen  in  battle 
on  land.  On  board  ship  injuries  arise  from  splinters  of  planks  and 
furniture,  pieces  of  iron,  etc.,  which  are  mobilized  by  bursting  shells, 
and  act  as  secondary  projectiles.  A  shell  exploding  a  magazine 
causes  many  injuries  by  burning  and  the  fumes  of  powder  gases  in 
confined  places  are  very  irritating  to  the  mucosae.  The  rending 
effects  of  the  sudden  displacement  of  air  by  detonating  explosions  is 
mentioned  as  an  additional  agent  in  causing  injury. 

The  injuries  on  board  ship  are  divided  as  follows:  (1)  contusions, 
(2)  abrasions,  (3)  penetrating,  (4)  perforating,  (5)  lacerating,  (6) 
mutilating,  and  (7)  burn. 

(1)  Contusions. — The  proportion  of  simple  contusions  are  relatively 
small  because  of  the  limited  range,  and  on  account  of  the  irregularity 

^  The  Surgical  and  Medical  History  of  the  Naval  War  between  Japan  and 
China,  1894-95,  by  Baron  Saneyoshi  and  Doctor  Suzuki,  Japanese  Navy. 


98  GUNSHOT   WOUNDS 

of  the  surface  of  the  projectiles,  which  invite  direct  injury  to  the  skin 
with  resulting  abrasion,  laceration,  etc. 

(2)  Abrasions  are  for  the  above  reasons  more  frequently  noted, 
and  they  are  often  incurred  by  fragments  striking  obliquely. 

(3)  Penetrating  Wounds. — These  wounds  are  inflicted  by  missiles 
possessed  with  low  velocity  and  they  find  lodgment  in  the  majority  of 
cases.  The  penetrating  wound  shows  but  one  wound — that  of 
entrance. 

(4)  Perforating  Wounds. — These  wounds  are  marked  by  a  wound 
of  entrance  and  one  of  exit.  They  are  usually  caused  by  small  pieces 
of  shell  about  the  size  of  a  .38  caliber  projectile  and  more  or  less  regular 
in  outline.  The  wound  of  entrance  conforms  to  the  shape  of  the  pro- 
jectile with  lacerated  edges,  showing  contusion  of  the  adjoining  tissues. 
Except  in  cases  where  the  skin  is  stretched  over  bone  or  tendon, 
the  wound  of  entrance  is  smaller  than  the  wound  of  exit.  The  wound 
of  exit  is  larger  at  times  when  the  fragment  leaves  the  body  with  its 
largest  diameter  at  right  angles  to  its  line  of  flight.  As  a  rule  the  resist- 
ance of  the  tissues  causes  the  fragment  to  turn,  so  that  its  longest 
diameter  remains  coincident  with  the  direction  in  which  it  is  moving, 
making  a  smaller  exit  wound  thereby. 

(5)  Lacerated  Wounds. — These  wounds  are  usually  inflicted  by 
a  shell  or  a  large  fragment.  They  are  marked  by  section  of  the  body 
in  two  parts,  the  severance  of  the  head,  hand  or  leg  from  the  body. 
Forms  of  injury  are  also  noted  where  continuity  of  the  body  still 
persists,  as  after  extensive  laceration  of  the  chest  or  abdomen. 

(6)  Mutilated  Wounds. — This  term  is  used  to  describe  the  wound 
in  cases  where  the  body  or  anatomical  part  is  mutilated  beyond 
recognition  of  its  human  form.  Those  sustaining  the  mutilation  of  a 
limb  survive  but  a  short  time  as  a  rule;  they  usually  succumb  to  shock 
rapidly. 

(7)  Burn. — This  is  by  far  the  most  frequent  injury  seen  in  naval 
combat.  It  comes  directly  from  the  explosion  of  shells  and  the  ignition 
of  ammunition  in  the  vicinity  of  the  explosion,  and  it  sometimes 
arises  from  steam,  which  is  liberated  from  containers  that  are  perfor- 
ated by  projectiles.  On  the  "Matsushima"  a  30-cm.  shell  struck  a 
gun-shield,  and  as  it  exploded  it  set  fire  to  some  ammunition  near  by. 
One  hundred  sailors  were  killed  and  wounded.  Twenty-five  ha,d  the 
body  destroyed  entirely;  one  suffered  mutilation  of  all  four  members; 
four  were  entirely  burned.  Of  the  seventy  wounded  twenty-two 
succumbed  to  burns  in  from  twenty-four  hours  to  a  period  of  six  weeks. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  99 

In  the  more  serious  cases,  the  face  was  blackened,  the  hair  singed,  the 
head  was  covered  with  black-yellowish  scabs,  the  eyes  were  closed,  the 
nostrils  were  obstructed  and  the  ears  were  tumefied,  the  mouth  was 
opened  with  difficulty. 

Saneyoshi  and  Suzuki  note  that  traumatic  delirium  is  the  most 
frequent  complication  of  burn  aboard  ship  and  that  of  all  injuries  in 
naval  combat  burn  is  the  most  painful. 

Rupture  of  Membrana  Tympani. — This  complication  is  often 
noted  as  a  result  of  reverberations  from  the  firing  of  cannons  and  the 
explosion  of  shells.  Rapid  displacement  of  air  in  the  vicinity  of  deto- 
nating ammunition  is  offered  as  an  additional  cause. 

Primary  Hemorrhage. — This  sjanptom  is  rarely  seen  in  shell 
wounds  for  reasons  already  referred  to.  But  two  deaths  were  reported 
in  the  Chino-Japanese  war,  one  from  a  shell  injury  of  the  larger  vessels 
of  the  abdomen,  and  the  other  from  a  piece  of  shell  which  cut  through 
the  neck  from  side  to  side  severing  the  trachea,  esophagus,  and  right 
carotid.  Secondary  hemorrhage  is  practically  absent,  presumably 
on  account  of  the  use  of  modern  methods  in  wound  treatment. 

Shock  is  not  so  dependent  upon  the  location  or  character  of  the 
wound  as  it  is  to  the  mental  state  of  the  individual  at  the  time  of  injury. 
Saneyoshi  and  Suzuki  cite  cases  of  shock  in  wounds  of  the  head,  chest 
and  abdomen,  as  well  as  in  cases  of  mutilated  injuries  of  the  limbs; 
and  again  cases  of  men  are  cited  who  labored  under  great  mental  excite- 
ment when  hit  and  who  though  fatally  wounded,  with  perforation  of 
the  abdomen,  mutilated  limbs,  etc.,  showed  no  symptoms  of  shock 
whatsoever  up  to  the  time  of  death.  Per  contra,  persons  were  seen  to 
go  into  a  state  of  shock  which  seemed  to  bring  on  paralysis  of  the 
nervous  system  from  proximity  to  a  bursting  shell  alone.  Burn  was 
responsible  for  many  of  the  cases  of  shock. 

Traumatic  delirium  as  a  symptom  is  noted  in  those  wounded  who 
were  in  proximity  to  the  explosion  of  large  shells.  Burn,  nerve  ex- 
haustion from  pain,  and  loss  of  sleep  are  mentioned  as  contributing 
causes  of  traumatic  delirium.  Out  of  a  total  of  629  injuries  received 
from  various  causes  in  the  above-named  war  50 . 2  per  cent,  were  due 
to  shells  and  shell  fragments  as  follows: 

Contusions 19  cases  in  14  persons. 

Abraded  wounds 47  cases  in  30  persons. 

Gutter  wounds 6  cases  in  6  persons. 

Wounds  attened  with  loss   of   soft 

tissues 4  cases  in  4  persons. 


100  GUNSHOT   WOUNDS 

Contused  wounds 97  cases  in      59  persons. 

Penetrating  wounds 57  cases  in      41  persons. 

Perforated  wounds 33  cases  in      30  persons. 

Lacerated  and  mutilated  wounds  occurred  as  follows: 

Hit  by  entire  shell 10  cases. 

Hit  by  fragment  shell 27  cases. 

Hit  by  iron  pieces 5  cases. 

In  the  neighborhood  of  shell  explosions,   causative 

effects  uncertain 8  cases. 

Uncertain  whether  hit  by  shell  fragment  or  iron  pieces  2  cases. 

By  compression 1  case. 

Total 53  cases. 

For  excellent  colored  plates  showing  wounds  by  shell  fragments, 
burn  and  other  lesions  which  occurred  in  the  Japan  and  China  War, 
1894-95,  see  the  Surgical  and  Medical  History  of  the  Naval  War  by 
Baron  Saneyoshi  and  S.  Suzuki,  Tokio. 

Dr.  Matthiolius^  also  reports  upon  the  gravity  o^  modern  naval 
war  wounds  from  the  battle  of  Chemulpo,  the  first  engagement  in  the 
Russo-Japanese  War.  The  Russian  Cruiser  "Varyag"  was  put  out 
of  commission  in  fifty  minutes  with  a  casualty  list  of  41  killed  and  64 
wounded,  being  18  per  cent,  of  her  effectiveness.  On  account  of  the 
large  penetrating  steel  shells,  men  were  completely  mutilated,  ampu- 
tations were  immediately  necessary  in  a  number  of  cases.  One  of  the 
sailors  received  160  wounds  from  the  explosion  of  one  shell.  In  the 
same  war  Dr.  Totsuka^  in  a  total  of  2321  casualties  in  naval  engage- 
ments, from  all  causes,  before  Port  Arthur  from  February  9,  to  October 
1,  1904,  gives  a  mortality  of  1022;  88  died  from  unknown  causes,  556 
of  the  wounds  were  severe  and  655  were  classed  as  slightly  wounded. 
The  exact  number  of  casualties  which  may  be  attributed  to  shells  or 
their  fragments  is  not  given.  He  states  that  the  shell  wounds  were 
generally  multiple.  In  36  wounded  there  were  62  wounds,  not  count- 
ing excoriations  and  slight  wounds.  Some  wounds  were  the  size  of  a 
pea,  others  large  enough  to  mutilate  a  limb.  The  wounds  consisted 
of  abrasions,  contusions,  blind  wounds,  perforating  wounds,  the  last 
of  these  being  less  often  seen,  owing  to  the  low  velocity  of  fragments 
Small  wounds  healed  rapidly,  but  the  large  wounds  all  suppurated. 

1  "Les  blessures  dans  la  guerre  Russo-Japonaise.  Dr.  MatthioHus,  Marine 
Imperiale  aUemande  Le  Caducee,  p.  11,  1904." 

2  Report  of  the  Wounded  admitted  to  the  Sasebo  Naval  Hospital  by  K.  Totsuka, 
Surgeon  General  I.  J.  Navy,  Sei-i-kwai  Med.  Jour.,  May  31,  1904. 


CHAEACTERISTIC   LESIONS    CAUSED   BY   PROJECTILES  101 

Pom-pom  Shell. — ^Wounds  from  this  projectile  or  its  fragments, 
do-  not  differ  from  injuries  inflicted  by  the  larger  shell.  The  shell 
is  fired  from  the  Maxim  automatic  gun  at  intervals  of  a  few  seconds. 
It  was  first  used  in  the  Boer  War.  Makins  states  that  the  effect  was 
principally  a  moral  one,  due  to  continuous  firing  of  the  gun  and  the 
unpleasant  noise  which  it  made.  The  shell  failed  to  explode  at  times 
and  as  it  was  sufficiently  small,  the  whole  projectile  was  known  to 
perforate  the  body  in  a  number  of  cases. 

"Wounds  by  Projectiles  from  Case  Shot,  Canister  and  Shrapnel. — 
The  former  of  these  have  been  altogether  superseded  by  the  use  of 
shrapnel.  Since  their  projectiles  are  similar  in  caliber,  shape  and 
weight,  and  generally  speaking  in  composition  to  the  shrapnel  bullet, 
and  as  the  balls  of  all  these  projectiles  are  possessed  with  low  velocity 
on  impact,  the  wounds  they  inflict  are  very  similar,  and  they  corre- 
spond to  the  description  of  wounds  by  shrapnel  balls.  Again,  shrapnel 
wounds  differ  in  no  respect  from  wounds  produced  by  spherical  balls 
from  low-veloc:ty  weapons  of  other  days.  The  canister  and  shrapnel 
balls  have  generally  been  spherical  in  shape  and  of  an  average  of  .  50 
calibers  in  diameter.  Whether  they  are  liberated  by  the  shock  of 
impact  or  a  time  fuse  the  velocity  is  low,  the  tendency  is  for  the  missiles 
to  lodge,  the  wounds  are  often  multiple,  and  they  nearly  always  sup- 
purate. There  were  but  1153  gunshot  wounds  from  grape^  and  canis- 
ter reported  in  our  Civil  War  of  1861-65  out  of  a  total  of  245,790 
wounds  from  all  kinds  of  projectiles.  Since  the  modern  shrapnel 
forms  about  80  per  cent,  of  the  artillery  ammunition  on  the  field  of 
battle  we  will  expect  more  casualties  from  this  source  in  the  future. 
In  recent  wars  the  proportion  of  shell  and  shrapnel  wounds  taken 
together  is  very  much  increased  in  number.  In  the  Manchurian 
campaign  Lynch^  states  that  for  the  first  Japanese  Army  the  mili- 
tary rifle  wounds  were  84  per  cent.,  shell  14  per  cent.,  and  bayonet 
0.9  per  cent.  This  army  was  engaged  in  field  operations  alone.  In 
the  third  army  which  had  only  siege  operations  at  Port  Arthur  and  but 
one  battle,  Mukden,  the  rifle  wounds  were  59  per  cent.,  cannon  19.63 
per  cent.,  bayonet  0 .  59  per  cent.  The  percentages  for  the  three  armies 
taken  together  is:  rifle  76.42,  cannon  15.78,  bayonet  0.63.  The 
remaining  percentages  figure  among  the  miscellaneous  and  untraceable. 

1  The  gi-ape  shot  of  the  Civil  War  was  made  of  about  9  spherical  iron  balls 
held  together  by  rings  and  cast-iron  plates.  They  separated  by  the  shock  of  dis- 
charge from  the  cannon. 

2  Reports  of  Military  observers,  etc..  Part  IV.  Report  by  Major  Charles 
Lynch,  U.  S.  Army,  1907. 


102 


GUNSHOT   WOUNDS 


f'i  *!^ 


% 


%^^^ 


Fig.  75. 


CHAHACTEE,.T,0   LESIONS   CAUSED  BV   PBO^CTZLES  JQS 


"^•■'^'tri:zc*'c-'^~i^ 


104 


GUNSHOT   WOUNDS 


In  the  field  all  wounds  classified  as  shell  wounds  were  practicallj^  due 
to  shrapnel. 

There  were  but  few  cases  of  shrapnel  wounds  reported  in  the 
Spanish-American  War.  In  the  South  African  War,  the  Boers  Avere 
poorly  provided  with  artillery.  They  used  shrapnel  with  little  effect- 
iveness owing  to  bad  marksmanship.  The  shrapnel  wounds  noted 
were  from  leaden  shrapnel  bullets  mostly  from  British  shells.  "The 
wounds  possessed  little  special  interest  except  from  the  fact  that  the 
bullets  were  often  retained"  (Makin).  The  same  author  saw  one 
patient  who  had  suffered  six  penetrating  wounds  from  the  bursting  of 
one  shrapnel.  Although  the  body  wounds  from  shrapnel  balls  are 
considered  uniformly  dangerous  to  life,  Makin  mentions  one  case  of 
remarkable    recovery    as   follows:  "A    Boer    wounded    at    Graspan. 


Fig. 


77. — From   Turko-Balkan   War    1912-13.     Bulgarian   artilleryman   wounded   by   a  bursting 
shrapnel  at  Lule  Burgas. 


Aperture  of  entry  (shrapnel)  opposite  eighth  left  costal  cartilage,  1 
inch  external  to  nipple  line.  The  opening  was  circular  and  surrounded 
by  an  area  of  ecchymosis  4  inches  in  diameter;  exit  4  1/2  inches  above 
and  to  the  right  of  the  umbilicus.  Patient  was  at  first  in  a  Boer  ambu- 
lance, and  only  seen  by  me  on  the  ninth  day.  At  that  date  he  was 
dressed  and  walking  with  a  gauze  pad  and  bandage  over  the  wounds. 
From  the  exit  wound,  which  was  1  inch  in  diameter,  protruded  a  piece 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


105 


of  sloughing  omentum,  the  margin  of  the  wound  being  everted  and 
raised  over  a  circular  indurated  area.  It  was  thought  best  to 
allow  the  sloughing  omentum,  which  was  very  foul,  to  separate 
spontaneously,  and  then  to  return  the  stump.  At  the  end  of  three 
weeks,  however,  the  slough  had  not  only  separated,  but  the  stump  had 
retracted,  and  only  a  small  granulating  surface  was  left,  which  healed 
spontaneously." 


Fig.  78. — Turko-Balkan  War  1912-13. 
Bulgarian  wounded  by  Turkish  shrapnel  at 
Kirk-Kahsse  Fauntleroy  collection. 


Fig.  79. — Turko-Balkan  War  1912-13. 
Bulgarian  infantryman  wounded  near 
Adrianople. 


From  the  Manchurian  campaign,  Lynch  states  that  the  shrapnel 
balls  were  prone  to  carry  foreign  material  from  the  men's  clothing 
into  the  wounds.  From  other  sources  we  gather  that  shrapnel  balls 
lodged  in  66  per  cent,  of  the  cases.  All  wounds  from  this  source  sup- 
purated. Wounds  of  the  chest  were  often  complicated  by  hemo- 
thorax, pneumothorax,  and  empyema — conditions  which  demanded 
prompt  attention.     Nearly  all  shrapnel  shots  of  the  abdomen  died 

Follenfant  in  the  same  campaign  states  that  shrapnel  wounds 
differed    according    to    the    part    of  the  shrapnel  that  inflicted  the 


106  GUNSHOT   WOUNDS 

injur3\  Some  of  the  shrapnels  held  the  explosive  in  the  head  of  the 
case.  The  latter  and  the  metallic  segments  within,  were  broken 
and  followed  the  cone  of  dispersion  with  the  balls.  The  wounds 
naturally  varied  with  the  character  of  the  missile — whether  it  happened 
to  be  part  of  the  casing  or  the  balls  contained  therein.  The  special 
feature  of  the  wounds  was  their  constant  infection,  as  a  result  no  doubt 
of  the  nature  of  the  lesion,  and  the  more  frequent  introduction  of 
shreds  of  clothing  into  the  wound.  In  the  Turko-Balkan  War  of 
1912-1913  the  ratio  of  wounds  by  shrapnel  has  exceeded  that  of  all 
preceding  wars.  Fauntleroy^  our  attache  in  the  field,  states  that  of 
25,000  wounded  received  in  the  hospitals  at  Sofia  from  the  battle- 
fields of  Adrianople,  Kirk  Kalisse  and  Lule  Burgas  and  other  engage- 
ments in  the  vicinity  the  shrapnel  wounds  averaged  between  25  and 
35  per  cent,  of  the  whole;  that  86  per  cent,  of  wounds  from  all  arms 
were  infected,  and  that  90  per  cent,  of  the  mutilating  operations  found 
necessary  were  the  result  of  infection.  His  observations  of  the  surgical 
wards  of  hospitals  m  Constantinople  lead  him  to  the  belief  that  the 
ratio  of  shrapnel  wounds  on  the  Turkish  side  will  be  about  33  per  cent, 
of  all  wounds  inflicted  at  the  battles  of  Kirk  Kalisse  and  Lule  Burgas, 
and  that  60  per  cent,  of  all  those  inflicted  at  Tchalgia  were  by  schrapnel. 
Other  observers^  found  the  frequency  of  shrapnel  wounds  in  the  Con- 
stantinople hospitals  as  high  as  80  per  cent  (Figs.  77  to  79). 

WOUNDS  FROM  GRENADES,  BOMBS  AND  MINES 

Hand  Grenades. — All  the  observers  in  the  Manchurian  campaign 
make  note  of  the  frightful  wounds  inflicted  by  the  hand  grenade. 
Hand  grenades  were  used  first  by  the  Japanese  at  the  siege  of  Port 
Arthur,  but  later  they  were  used  on  both  sides  during  the  remainder 
of  the  war.  McPherson  saw  many  wounds  inflicted  by  this  device 
and  they  were  difficult  to  treat  satisfactorily.  The  wounds  were 
multiple.  The  injuries  were  often  caused  by  the  shattering  effects  of 
pyroxylin  gas.  Parts  were  completely  carried  away  or  so  damaged 
as  to  require  amputation.  Another  class  of  wounds  was  caused  by 
strips  of  the  casing.  These  were  deep,  lacerated  wounds,  leaving  ugly 
scars  and  causing  much  disfigurement  when  the  face  was  injured. 

1  Report  to  the  A.  G.  O.,  February,  1913,  by  Major  P.  C.  Fauntleroy,  M.  C, 
U.  S.  Army. 

2  Lucas-Championierre,  J.  M.  Chirurgien  du  Croissant  Rouge,  etc.  J.  de 
Med.  et  de  Chirurgie  Pratique,  No.  24,  Dec.  25,  1912. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


107 


The  wounds  were  at  first  of  a  deep  yellow  color,  the  wounded  suffered 
great  pain,  which  persisted  long  after  the  wound  had  commenced  to 
heal.     Fig.  80. 

Some  of  the  wounds  caused  by  the  explosion  of  the  grenades  are 
described  as  very  small  and  numerous,  due  to  the  lodgment  of  metallic 
particles.  In  addition  to  the  physical  injuries  mentioned  the  worst 
effects  of  the  explosion  were  moral.  Only  the  best  seasoned  troops 
stood  the  fire. 


Fig.  80. — Wound  produced  by  explosion  of  hand  grenade,  Russo-Japanese  War.      (Lynch.) 

Wounds  from  Bombs  and  Mines. — The  wounds  produced  by 
bombs  are  similar  to  those  arising  from  the  high  explosives  already 
referred  to.  The  injuries  from  terrestrial  mines  are  also  similar,  with 
the  addition  of  the  lodgment  of  foreign  bodies  in  the  wounds,  composed 
of  gravel,  dirt,  and  splinters  of  wood.  The  latter  came  from  the  boxes 
in  which  the  explosive  is  buried  beneath  the  surface.  Such  wounds 
are  prone  to  develop  the  virulent  infections  arising  from  the  bacillus 
aerogenes  capsulatus  and  the  bacillus  of  tetanus. 

Wounds  from  Pistols  and  Revolvers. — Our  remarks  upon  the 
subject  of  the  stopping  power  of  pistols  and  revolvers,  and  the  illus- 
trations exhibited  in  another  part  of  this  chapter  bear  to  a  large  extent 
upon  the  characteristic  efi^ects  of  the  wounds  produced  by  the  above- 


108  GUNSHOT   WOUNDS 

named  weapons.  The  calibers  of  these  weapons  usually  vary  between 
.22  and  .47.6,  the  latter  being  used  but  seldom.  The  majority  of  the 
wounds  come  from  .38  caliber  bullets. 

Projectiles  from  pistols  and  revolvers  having  lower  velocities  than 
rifle  projectiles  are  less  apt  to  fracture  bone  and  they  more  often  lodge 
than  the  bullets  of  the  high-power  rifles.  As  a  rule  the  length  of  the 
pistol  or  revolver  projectiles  is  much  shorter  than  the  longer  stable 
bullet  of  the  reduced  caliber  rifles.  The  length  of  the  latter  is  usually 
four  diameters;  and  for  the  smaller  bore  rifles,  like  the  .25.5  caliber  of 
the  Japanese  Army,  the  length  of  the  bullet  is  as  much  as  five  diameters. 
The  ballistician  is  wont  to  increase  the  length  of  his  bullet  as  he  reduces 
its  caliber,  and  he  does  this' to  insure  the  stability  of  the  bullet  in  flight, 
to  keep  it  point  on.  This  adds  to  both  range  and  penetration,  and  for 
a  military  projectile  it  is  very  advantageous.  The  wound  which  such 
a  bullet  inflicts  is  generally  round,  corresponding  to  the  caliber  of  the 
bullet.  The  channel  is  clean  cut  as  it  were,  with  a  minimum  of  con- 
tusion, laceration  and  hematoma.  The  bone  lesion  is  not  so  severe  ex- 
cept for  the  proximal  ranges.  The  epiphyseal  ends  of  bones  as  we  have 
already  stated  are  generally  perforated,  with  very  little  if  any  shat- 
tering. The  pistol  and  revolver  bullets  on  the  other  hand  are  much 
shorter  by  comparison.  The  length  of  any  of  them  seldom  exceeds  two 
diameters  and  some  of  them,  like  the  .45.5  caliber  man  stopper;  the 
.45  caliber  lead  bullet  with  blunt  point,  the  .38  caliber  jacketed  bullet 
for  the  automatic  Colt's,  are  less  than  two  diamteers  in  length.  The 
bullets  from  pistols  and  revolvers  are  thus  rendered  very  unstable  as 
a  rule.  The  least  resistance  on  impact  causes  them  to  tumble,  and 
then  to  crash  through  the  tissues  end  over  end,  inflicting  thereby 
uglier  wounds,  wounds  exhibiting  laceration,  contusion,  hematomata, 
and  all  the  characteristics  which  favor  the  reduction  of  local  resistance 
in  the  tissues. 

Blank  Ammunition  and  Toy-pistol  Wounds. — Gunshot  wounds 
from  toy-pistols  are  of  special  interest  to  American  surgeons,  because 
they  figure  extensively  in  American  surgical  literature  in  connection 
with  the  production  of  tetanus.  The  same  character  of  wound  has 
been  noted  by  Bonnette,  Schernning  and  others  abroad,  with  similar 
complications.  As  we  will  point  out  in  the  chapter  on  "Infection  of 
Gunshot  Wounds"  the  injuries  from  the  toy-pistol  and  other  blank 
ammunitions  are  usually  delivered  at  close  range.  The  impact  of 
such  a  charge  causes  much  laceration,  contusion,  hematomata — the 
very  conditions  that  augment  the  tendency  to  the  development  of 


CHARACTESISTIC    LESIONS    CAUSED   BY    PROJECTILES 


109 


the  virulent  infections.  It  is  for  this  reason  that  toy-pistol  wounds 
and  wounds  from  blank  ammunition  deserve  special  consideration. 
Toy -pistol  wounds  in  this  country  are  inflicted  accidentally  about  the 
time  of  the  anniversary  of  our  National  Independence,  and  abroad  the 
blank  ammunition  wounds  occur  about  the  time  of  the  army  maneu- 
vers, in  the  sham  battles  which  accompany  these  exercises. 

Wounds  from  Shot-guns. — The  characteristic  features  of  wounds 
inflicted  by  small  shot  from  the  class  of  weapons  known  as  shot-guns 
differ  materially  with  the  distance  from  the  gun  at  the  time  of  dis- 


FiG.  81. — Radiogram  showing  lodged  pellets  from  shot-gun  wound.  Compound  commin- 
uted fracture  fibiila.  Loose  fragments  removed.  Later  infection  from  bacillus  serogenes  capsula- 
tus  developed,  necessitating  amputation.     Army  Medical  School  collection. 


charge,  the  size  of  the  shot,  the  amount  of  propellant,  the  manner  of 
loading  or  the  kind  of  cartridge.  The  cone  of  chspersion  made  by  the 
shot  is  influenced  naturally  by  all  of  the  foregoing,  viz.,  the  distance, 
size  and  number  of  the  shot,  the  amount  of  propellant,  etc.  Close- 
range  shots  are  marked  by  total  destruction  of  tissues,  laceration, 
hematoma  and  fracture  of  bone  with  extensive  comminution,  and  by 
perforation  and  lodgment  of  individual  pellets  (Figs.  81  to  84). 

Gunshot  Wounds  from  Small  Target  and  Flobert  Rifles. — The  bore 
of  these  weapons  is  generally  .22  to  .32  calibers.  The  projectiles 
may  be  round,  or  elongated,  the  latter  being  of  two  sizes,  the  long  and 


110 


GUNSHOT   WOUNDS 


short.  The  weight  of  the  projectile  of  the  .22  cahbers  is  about  15 
grains,  that  of  the  latter  about  60  grains.  The  velocity  of  the  U.  S. 
Army  target  rifle  ammunition  is  969  f.s.  For  a  very  interesting  fatal 
case  of  gunshot  injury  of  the  head  by  the  .  22  caliber  target  rifle  gener- 
ally used  in  this  countrj^  see  Chapter  VI,  page.  170. 


Fig.  82. — Radiograph  showing  lodged  shot  in  upper  thigh.  Wounded  accidentally  by  shot- 
gun within  distance  of  4  ft.  After  the  surgeons  had  removed  all  missiles  in  sight,  over  90  pellets 
were  revealed  by   X-ray.     Army   Medical   School  collection. 

Doepner^  gives  some  very  interesting  cases  of  fatal  injurj^from  the 
projectile  of  the  Flobert  rifle  (Fig.  85).     Fig.  A,  p.  113,  is  a  deformed 

1  Doepner.  Die  gerichtsaertztliche  Bedeutung  der  Flobert  waffen.  Aertzt. 
Sachverst.  Ztg.,  Berlin,  1908,  XIV.,  349  ff. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES 


111 


Flobert  rifle  bullet  which  passed  through  the  frontal  bone  of  a  girl 
nine  years  old,  and  perforated  the  brain  with  fatal  results.  Fig.  C 
is  a  bullet  that  penetrated  the  left  hip  in  a  man  sixty-eight  years 
old.  The  accident  was  followed  by  fatal  tetanus  on  the  nineteenth 
day.     Fig.  D  penetrated    a  rib    and  the    entire    lung,    causing  fatal 


Fig.  83. — A  radiograph  taken  in  1911  of  James  A.  Stewart,  Co.  "I"  81st  Ind.  Vol.  Inf.,  and  "G" 
45th  Veteran  Reserve  Corps,  who  was  accidentally  shot  in  the  right  hand  by  a  hunter,  Feb.  8, 
1857,  the  shot  entering  the  wrist  and  palm  of  the  hand.  The  fingers  are  strongly  flexed,  and  there 
is  considerable  atrophy  of  the  muscles.  U.  S.  Soldiers  Home  collection.  Dr.  A.  B.  Herrick,  X- 
rayist. 

outcome  from  pleuritis  and  pneumonia.  The  other  illustrations 
show  deformed  bullets  from  experimental  shots  on  cadavers  and 
boards. 

Wounds  by  Air-gun  Projectiles. — The  projectiles  of  air-guns  are 
about  .22  calibers,  round  in  shape,  and  composed  of  lead.     The  pro- 


112 


GUNSHOT    WOUNDS 


pellant  is  compressed  air.  The  energy  of  the  bullet  is  sufficient  to 
penetrate  the  tissues  and  fatal  wounds  from  air-guns  figure  in  the 
hterature.     The  bullet  causes  a  more  or  less  contused  and  lacerated 


Fig.  84. Radiogram  in  case  of  J.  M.  showing  ununited  fracture  of  humerus  and  lodged  shot. 

Wounded  June  25,  1S60,  by  accidental  discharge  of  shot-gun,  distance  2  ft.     Exposure  made  Oct. 
1901.     X-ray  Laboratory  U.  S.  Soldiers  Home.     Dr.  A.  B.  Herrick,  X-rayist. 

wound.     The  knee,  eye,  and  abdominal  cavity  have  been  penetrated 
by  the  projectile  with  disabling  and  fatal  results. 


CHARACTERISTIC    LESIONS    CAUSED   BY    PROJECTILES  113 


Fig.  85. — Photographs  of  Flobert  rifle  bullets  magnified  three  and  one-half  times. 


CHAPTER  III 

Symptoms  of  Gunshot  Wounds 

The  symptoms  of  gunshot  wounds  are  (a)  pain,  (b)  shock,  (c) 
hemorrhage,  and  (d)  thirst.  The  first  and  last  of  these  symptoms, 
viz.,  pain  and  thirst,  are  always  present.  Lodgment  of  a  projectile, 
powder-burn  and  multiple  wounds  when  present  are  usually  referred 
to  as  complications  of  a  primary  nature,  and  not  as  symptoms. 

(a)  Pain. — The  amount  of  pain  after  the  receipt  of  a  gunshot 
wound  depends  upon  the  situation  of  the  w^ound,  its  gravity,  and  the 
amount  of  tissue  involved  in  the  traumatism.  We  have  stated  al- 
ready that  the  amount  of  tissue  involved  is  proportional  to  the  veloc- 
itj^  of  the  projectile,  its  sectional  area,  and  the  resistance  which  the 
tissue  traversed  offers  on  impact.  Writers  on  military  surgery  have 
observed  interesting  cases  of  what  is  called  referred  sensation  among 
the  injured.  ]Makins  mentions  the  case  of  a  man  who  was  struck  in 
the  head  who  first  felt  pain  in  the  great  toe,  and  another  who  was 
struck  in  the  abdomen  felt  pain  in  his  foot  only.  A  Civilian  War  Hos- 
pital^ in  the  South  African  campaign  mentions  the  case  of  a  man  who 
"fancied  himself  hit  in  the  foot  and  at  once  sat  down  and  proceeded 
to  take  off  his  boot  with  the  intention  of  appl.ying  a  first-aid  dressing. 
His  surprise  was  great  when  on  taking  off  his  sock  he  found  no  wound. 
He  subsequently  discovered  that  he  was  shot  through  the  upper  part 
of  the  thigh." 

In  the  heat  and  excitement  of  battle  men  have  been  hit  by  the 
missiles  of  the  old  armament  without  knowing  for  a  time  at  least 
that  they  were  injured,  and  what  is  true  of  the  old  armament  is  true 
of  the  new,  even  more  so.  At  Santiago  we  repeatedly'  questioned  men 
who  came  from  the  front  during  the  battle  on  this  point.  Some  said 
thej^  felt  a  sudden  rap  followed  by  a  feeling  of  burning;  or  a  blow,  as 
from  a  hammer,  a  stone,  or  a  cane.  Others  likened  the  pain  to  the 
sting  of  an  insect.  Many  of  the  men  stated  that  they  did  not  know 
when  they  were  injured  and  thej^  were  ignorant  of  the  presence  of  a 
wound  until  their  attention  was  called  to  it  by  a  comrade,  or  the  sight 
of  blood.     Pain  when  present  was  more  often  felt  at  the  wound  of 

1  A  Civilian  War  Hospital  by  the  Professional  Staff  thereof,  etc.  London,  1901. 

114 


SYMPTOMS  OF  GUNSHOT  WOUNDS  115 

exit.  The  wounded  experienced  a  sense  of  stiffness  about  the  part  hit, 
which  caused  pain  on  motion  and  the}"  preferred  to  remain  quiet. 
Makins  refers  to  an  amusing  instance  of  entire  absence  of  initial  pain 
in  a  man  who  was  shot  through  the  buttock,  the  bullet  subsequently 
traversing  the  abdominal  ca\dty.  The  patient  was  ignorant  of  having 
been  wounded  until  on  undressing  he  found  blood  on  his  trousers  and 
exclaimed  "why  I  have  got  this  bloody  dysentery."  Nevertheless, 
the  wound  was  so  serious  in  its  nature  that  he  died  as  a  result  of  it  in 
thirty-six  hours. 

The  sensation  of  pain  is  apt  to  be  blunted  to  the  point  of  anes- 
thesia in  wounds  from  sohd  shot,  shell  fragments,  and  the  high-power 
rifle  bullets  at  close  range  against  resistant  bone.  In  such  cases  the 
tissues  are  devitalized  and  there  is  a  deadening  of  sensation  in  the 
injured  part.  In  injuries  of  this  magnitude  there  is  always  more  or 
less  shock,  and  the  lack  of  appreciation  of  local  pain  may  in  some  cases 
at  least  be  due  to  the  effects  of  constitutional  shock. 

(b)  Constitutional  Shock. — ^Military  surgeons  dwell  on  the  train 
of  symptoms  of  a  depressing  kind  which  is  called  shock,  and  which 
seems  to  be  specially  marked  in  gunshot  wounds.  In  cases  showing 
extensive  injury  like  the  wounds  involving  comminution  of  large  resis- 
tant bone  so  common  in  shots  by  the  high-power  rifle  at  proximal  ranges, 
in  penetrating  wounds  of  the  large  cavities,  and  again  in  wounds  from 
the  artiller}'  class  of  missiles  like  shell  fragments,  or  in  the  case  of  a 
limb  carried  away  by  a  solid  shot,  there  is  commonly  present  an 
immediate  disturbance  of  the  nervous  system  which  exhibits  decided 
bodily  and  mental  depression,  the  amount  and  duration  of  which  is  as 
a  rule  not  proportioned  to  the  gravity  of  the  injury.  The  patient  in 
most  cases  is  seized  with  extreme  pallor  of  the  skin  and  mucous  sur- 
faces; the  surface  of  the  body  is  cold  and  clammy;  a  state  of  tremor, 
notably  of  the  limbs,  supervenes;  the  pupils  are  dilated,  the  heart's 
action  is  irregular,  the  pulse  is  weak,  thready,  irregular,  and  imper- 
ceptible at  the  vrrist  in  marked  cases;  the  respiratory  movements  are 
irregular  and  shallow,  usualh"  accompanied  bj"  deep  sighing  respira- 
tion; the  features  show  mental  apathy  or  anxiety  and  distress;  there  is 
impairment  of  superficial  sensibility,  and  nausea  and  vomiting  are 
often  present.  In  the  stress  of  battle  there  is  often  a  kind  of  shock 
attended  with  great  excitement  and  much  restlessness,  in  which  the 
movements  of  the  patient  are  difficult  to  control,  the  reverse  of  the 
bodily  and  mental  depression  already  referred  to.  We  knew  a  vigor- 
ous young  officer  in  the  Sioux  campaign  of  1876  who  was  shot  in  the 


116  GUNSHOT    WOUNDS 

head,  wrist,  groin,  knee  and  twice  through  the  body,  who  exhibited 
pallor  and  other  symptoms  of  shock.  When  we  first  saw  him  he  was 
carried  by  four  men  who  held  the  four  corners  of  a  blanket  on  which 
he  lay.  He  uttered  piercing  cries  at  the  top  of  his  voice,  he  labored 
under  great  excitement  and  talked  incessantly.  He  was  perfectly 
conscious,  asked  for  water,  and  made  an  effort  to  give  a  message  to 
be  transmitted  to  his  family,  but  he  was  soon  seized  with  the  wild 
agitation  of  a  moment  before  and  failed  to  finish  the  message.  He 
continued  in  this  restless  state  until  death  took  place  a  half  hour 
later. 

In  other  cases  the  mental  tension  of  the  wounded  whose  tempera- 
ment is  at  all  times  placid  will  apparently  control  or  suppress  a  state 
of  shock  for  an  indefinite  time  after  the  injury.  A  captain  of  the  1st 
Cavalry  in  the  Guaicemus  fight  in  the  Santiago  campaign  was  shot 
through  the  body  bj^  a  Mauser  bullet.  The  bullet  made  a  complete 
perforation  of  the  body  from  back  to  front  involving  the  right  lobe  of 
the  liver  and  fracturing  two  ribs.  He  was  conscious  at  the  time  that 
he  had  been  hit  from  the  flow  of  blood  on  his  clothing  and  a  sensation 
as  if  he  had  been  struck  by  a  stone,  but  he  was  engaged  in  aligning 
his  men  and  correcting  some  confusion  in  his  troop  incident  to  a  sudden 
volley  after  an  ambuscade,  and  he  completed  what  he  had  set  to  do 
before  he  was  shot,  and  then,  without  ever  falling  to  the  ground  he 
proceeded  to  the  dressing  station,  a  distance  of  75  yards,  where 
he  placed  himself  under  the  care  of  a  surgeon,'  after  which  a 
certain  amount  of  shock  supervened.  He  eventually  recovered  with- 
out operation. 

The  placidity  of  the  Arab  and  resistance  against  shock  is  well  told 
bj^  Captain  Engenio  de  Sarlo  in  the  recent  Italo-Turkish  war  in  North 
Africa.^  An  Arab  was  wounded  by  the  explosion  of  a  grenade.  There 
was  a  large  abdominal  wound,  the  omentum  and  a  large  mass  of  intes- 
tines protruding  through  the  wound,  with  perforation  of  the  protruded 
intestines  in  various  parts,  and  entire  ablation  of  the  right  hand.  The 
wounded  was  in  good  condition  when  the  reporter  commenced  to  per- 
form a  laparotomy  convinced  at  the  same  time  that  the  operation  would 
be  of  no  avail.  He  sewed  up  a  number  of  lateral  tears  and  a  circular  rent 
in  the  intestines  and  left  a  drain  after  partially  sewing  up  the  abdominal 
wall;  he  then  amputated  by  a  circular  flap  in  the  lower  third  of  the 
forearm.     The  wounded  endured  the  various  steps  of  the  operations 

1  Le  Caducee,  Nov.  16,  1912,  comments  on  the  Report  of  Captain  de  Sarlo 
on  the  wounded  at  Derna  bj'  Ed.  Laval. 


SYMPTOMS    OF   GUNSHOT   WOUNDS  117 

without  complaint,  on  the  contrary,  he  thanked  the  operator  for  his 
services  from  time  to  time.  Immediately-  after  the  operation  he  asked 
to  be  returned  to  his  home  where  he  was  taken  at  once,  and  where  he 
immediately  sat  down  and  commenced  to  eat  some  dates.  No  fur- 
ther mention  is  made  of  the  case. 

Sir  Thomas  Longmore,  referring  to  cases  where  the  temperament 
can  exercise  the  faculty  of  control  over  alarm  and  depression,  cites 
the  case  of  a  "sergeant  who  had  the  left  arm  completely  carried  off 
near  the  shoulder  hj  a  cannon  ball  at  Waterloo.  In  this  condition 
he  started  off  and  rode  upright  all  the  way  from  the  field  of  battle  to 
Brussels,  a  distance  of  15  miles."  On  reaching  the  hospital  he  became 
utterly  prostrate. 

A  temperament  the  opposite  of  the  one  just  mentioned,  one  that  is 
easil}^  alarmed,  may  be  overcome  with  shock  after  receiving  a  slight 
wound.  In  sush  a  case  it  is  not  easy  to  determine  the  sj^mptoms  of 
shock  from  those  of  fear  and  cowardice. 

The  duration  of  shock  is  variable  and  difficult  to  foretell.  Some 
patients  in  profound  shock  will  recover  in  a  comparatively  short  time, 
while  others  in  moderate  shock  maj^  remain  prostrate  for  an  indefinite 
period,  depending  most  likey  on  individual  peculiarities. 

Treatment  of  Shock. — There  are  some  cardinal  facts  connected 
with  shock  which  should  be  borne  in  mind: 

(1)  One  wounded,  in  a  state  of  shock,  should  always  be  carefully 
guarded  bj^  trained  assistants  when  reaction  sets  in.  During  shock 
the  weak  condition  of  the  heart  often  starts  hemorrhage  from  injured 
vessels  that  bleed  freety  as  soon  as  the  blood  pressure  is  re-established 
and  the  heart  commences  to  regain  its  normal  volume. 

(2)  When  in  a  state  of  shock  from  severe  injury  the  temperature 
falls  to  about  96.8°  F.,  the  prognosis  is  grave  and  the  patient  usually 
dies. 

(3)  All  the  wounded  who  fail  to  recover  their  temperature  in  about 
four  hours,  or  in  whom  reaction  is  not  in  proportion  to  the  depression, 
should  be  considered  as  seriously  injured  and  unfit  to  undergo  operation. 
''The  thermometer  is  an  unfailing  indication  as  to  when  operative 
interference  may  be  permissible"  (M.  Retard). 

(4)  Operations  beyond  ligation  of  vessels  to  arrest  hemorrhage 
should  be  avoided  during  the  state  of  shock,  and  transport,  unless 
imperative,  should  be  delayed. 

The  relief  of  shock  is  directed  toward  measures  calculated  to 
restore   the   blood   pressure.     The   possibility   of   secondary   hemor- 


118  GUNSHOT    WOUNDS 

rhage  should  be  remembered  and  the  aim  of  the  surgeon  should  be 
toward  a  gradual  reaction.  The  first  indication  toward  this  end  is 
the  placing  of  the  patient  in  the  recumbent  posture  with  his  head  on  a 
level  with  the  body,  and  restoration  of  the  body  temperature  by  the 
use  of  heat  applied  externally  in  the  way  of  warm  woolen  blankets, 
hot-water  bags,  bottles,  etc.,  with  due  care  to  prevent  burns  of  the 
surface.  Brandy  or  whiskey,  diluted  with  hot  water,  should  be 
gradually  administered.  An  enema  of  2  or  3  pints  of  normal  salt 
solution  is  highly  recommended  by  many  surgeons.  Transfusion 
of  saline  solutions  in  profound  shock  is  often  resorted  to  with  marked 
results,  supplemented  by  oxygen  inhalations.  Of  the  drugs  in  use, 
strychnia  is  one  of  the  most  popular,  injected  hypodermically.  The 
Japanese  in  the  Russo-Japanese  War  are  said  to  have  resorted  to  liquor 
camphorsB  as  follows:  camphor  1  part,  ether  4  1/2  parts,  and  olive 
oil  4  parts.  This  was  used  subcutaneously  with  marked  benefit.  It 
was  the  favorite  remedy  on  the  firing  line.^  In  this  country  injections 
of  adrenalin  with  normal  salt  solution  are  extensively  employed. 
Four  or  5  minims  of  adrenalin  are  dissolved  at  the  time  it  is  to  be  used 
in  500  c.c.  of  sterile  salt  solution  to  be  injected  in  the  cellular  tissue 
of  the  flanks,  buttocks  or  behind  the  breasts. 

(c)  Hemorrhage. — Hemorrhage  as  a  symptom  of  gunshot  wounds 
may  be  divided  into  (1)  external  primary,  (2)  recurrent  hemorrhage, 
and  (3)  internal  primary  hemorrhage. 

(1)  External  primary  hemorrhage  refers  to  hemorrhage  that 
comes  from  injured  vessels  which  are  situated  external^  and  which 
may  be  readily  reached  and  ligated  by  the  surgeon.  Here  we  refer 
more  especially  to  the  vessels  of  the  extremities  and  neck.  Hemor- 
rhage coming  from  the  former  situations,  such  as  the  vessels  of  the 
arm,  forearm,  thigh  and  leg,  exclusive  of  the  exposed  vessels  about  the 
ankle  and  wrist,  was  considered  very  frequent  once  upon  a  time 
judging  from  the  liberal  distribution  of  tourniquets  in  the  pouches  of 
members  of  the  relief  corps.  As  a  matter  of  fact  external  primary 
hemorrhage,  under  the  designation  mentioned,  may  be  said  to  be  rare. 
The  Surgical  History  of  our  Civil  War  shows  that  primary  hemorrhage 
only  came  under  the  observation  of  the  surgeons  in  5  per  cent,  of  all 
wounds  and  in  3  per  cent,  in  the  Crimean  War.  Of  the  1400  wounded 
at  Santiago  in  1898,  the  large  majority  of  them  being  from  the  re- 
duced  caliber   Mauser  bullet,  no  death  from  external  primary  hem- 

^  Russo-Japanese  War.  Medical  and  Surgical  Reports  of  Lt.  -  Col.  W.  G. 
McPherson,  R.  A.  M.  C. 


SYMPTOMS    OF   GUNSHOT   WOUNDS  119 

orrhage  was  recorded  and  no  vessel  was  tied  on  the  field  to  arrest 
this  kind  of  hemorrhage.  The  experience  of  the  English  surgeons  in 
the  Boer  War  agrees  with  the  observations  of  surgeons  in  former  wars. 
Makins/  referring  to  his  experience  in  the  South  African  War,  states 
that  external  hemorrhage  from  the  vessels  of  the  limbs  or  even  of  the 
neck  proves  responsible  for  a  remarkably  small  proportion  of  the  deaths 
on  the  field.  This  statement  may  be  made  with  confidence  since  it  is 
not  only  his  own  experience,  but  it  coincides  with  what  he  was  able  to 
gather  from  the  experience  of  many  medical  officers  on  duty  with  bearer 
companies.  He  states  that  only  one  case  of  rapid  death  due  to  bleed- 
ing from  a  limb  artery  was  recounted  to  him.  This  was  the  case 
of  a  man  who  was  wounded  in  the  brachial  artery  and  who  succumbed 
in  20  minutes,  during  the  time  that  he  was  being  transported  to  the 
dressing  station.  Col.  W.  F.  Stevenson  of  the  R.  A.  M.  C,  who  was 
in  charge  of  the  line  of  communication  in  South  Africa,  states  that 
''severe  external  primary  hemorrhage  from  small  bore  bullet  wounds 
of  the  vessels  of  the  limbs,  except  when  these  are  injured  in  regions 
where  they  are  superficial,  is  uncommon." ^  Reports  of  Follenfant^ 
on  the  Russian  side  in  the  Russo-Japanese  War  confirm  the  rarity  of 
avoidable  external  primary  hemorrhage  on  the  field  in  the  Manchurian 
campaign,  and  it  may  be  stated  as  a  paradox  that  nearly  all  observers 
in  recent  wars  agree  that  blood-vessels  are  more  often  wounded  with 
the  use  of  the  present  armament  than  formerly,  and  yet  external 
primary  hemorrhage  of  an  alarming  kind,  always  rare  in  battle,  is 
seen  less  often  than  ever  before.  The  following  explanation  is  given 
for  this  apparent  contradiction:  formerly  when  the  large  leaden 
bullet  with  a  hemispherical  head  moving  at  a  comparatively  slow 
rate  of  speed  collided  with  one  of  the  larger  vessels  the  latter  was 
pushed  aside  and  if  it  was  cut  across  or  otherwise  injured,  there  was 
no  great  tendency  to  primary  hemorrhage  because  of  the  irregularity 
of  the  wound  in  the  vessel  coats.  The  armored  bullets  of  reduced 
caliber  are  more  definite  in  the  work  which  they  accomplish;  they 
cut  the  vessels  like  a  knife  because  of  their  superior  velocity,  smaller 
caliber  and  more  pointed,  ogival  heads.  The  mechanical  effects  of 
forcing  the  bullet  through  the  tissues  is  done  so  rapidly  owing  to  greater 
velocity  that  there  is  no  time  for  the  vessel  to  be  pushed  aside.  When 
one  of  the  large  vessels  is  hit  fairly  the  small  caliber  of  the  bullet 

^  Surgical  Experiences  in  South  Africa  by  George  Henry  Makins,  F.  R.  C.  S. 
2  Wounds  in  War  by  Col.  W.  F.  Stevenson,  R.  A.  M.  C.     Ed.,  1910. 
2  Op.  cit. 


120  GUNSHOT   WOUNDS 

permits  it  to  make  two  clean-cut  perforations  going  in  and  out,  leaving 
no  lacerated  edges.  There  is  in  such  a  wound,  as  far  as  the  vessel  is 
concerned,  every  opportunity  for  immediate  fatal  external  primary 
hemorrhage.  When  the  vessel  is  hit  at  a  tangent  a  clean  opening  is 
cut  on  one  side  which  again  affords  every  chance  for  immediate  hemor- 
rhage, and  fatal  consequences  would  doubtless  ensue  in  either  case 
except  for  the  following  reasons:  the  channel  of  the  wound  being 
small,  the  narrow  track  is  readily  obstructed  by  a  change  in  the 
position  of  the  apertures  in  the  muscles,  intermuscular  septa,  fascias, 
etc.,  which  causes  obstruction  in  the  continuity  of  the  channel,  hence 
the  rarity  of  external  primary  hemorrhage  from  modern  rifle  bullets. 
In  such  wounds  there  may  be  no  external  evidence  of  hemorrhage,  or 
possibly  but  a  momentary  spurt  of  blood,  which  is  arrested  as  soon 
as  the  muscles  change  their  position.  Wounds  of  this  character  result 
in  different  kinds  of  aneurysms,  which  are  more  common  in  gunshot 
wounds  now  than  hitherto,  and  which  will  be  discussed  under  wounds 
of  blood-vessels  in  another  chapter. 

(2)  Recurrent  hemorrhage  may  be  external  or  internal.  In  this 
form  of  hemorrhage  the  temporary  obstruction  in  the  way  of  interven- 
ing layers  of  tissue  or  clot  gives  way  and  favors  the  recurrence  of 
hemorrhage.  Makins,  in  his  extensive  experience  in  the  Boer  War, 
noted  the  occurrence  of  hemorrhage  in  several  cases  in  the  lower  ex- 
tremities on  the  second  and  third  days,  which  he  styles  recurrent  hem- 
orrhage and  for  which  ligation  of  the  popliteal  or  femoral  artery  became 
necessary. 

(3)  Internal  Primary  Hemorrhage. — We  include  in  this  classifica- 
tion hemorrhage  that  occurs  from  injury  to  blood-vessels  in  the  large 
cavities,  like  the  thorax,  the  upper  and  lower  abdomens.  The  vessels 
in  these  localities  have  not  the  firm  support  of  those  in  the  limbs  and 
injury  to  their  coats  by  modern  rifle  bullets  which  make  clean-cut 
perforations  bleed  freely  as  a  rule.  In  such  cases  Makins^  states  that 
"the  potential  space  offered  by  the  peritoneal  or  pleural  cavities  favors 
the  ready  escape  of  blood  from  the  wounded  vessel,  while  the  tendency 
of  the  blood  effused  into  serous  cavities  to  rapid  coagulation  is  notably 
slight."  The  mortality  from  this  source  on  the  field  of  battle  has  al- 
ways been  considered  very  high  before  and  since  the  change  in  the 
armament.  Surgeon  J.  A.  Liddell,  of  the  U.  S.  Army,  quoted  by  Otis, 
was  convinced  that  a  large  proportion  of  the  killed  in  battle  perished 
directly  from  loss  of  blood  as  a  result  of  internal  primary  hemorrhage. 

1  Op.  cit. 


SYMPTOMS  OF  GUNSHOT  WOUNDS  121 

Stevenson,^  writing  on  the  effects  of  present-day  rifle  bullets,  believes 
that  "it  is  much  nearer  the  true  state  of  the  case  to  say  that  the  great 
majority  of  those  who  die  before  succor  can  reach  them  succumb  from 
primary  hemorrhage.  Some  of  the  observers  place  the  number  of 
deaths  from  this  cause  as  high  as  85  per  cent."  The  statement  is  not 
surprising  to  those  who  have  been  on  the  line  and  witnessed  the  death 
struggle  of  the  wounded.  Body  wounds,  when  death  is  imminent,  are 
always  attended  with  extreme  pallor,  great  thirst,  fluttering  pulse, 
lowering  temperature,  etc.  These  symptoms  might  well  be  ascribed 
to  shock,  but  in  the  latter  restoratives  usually  relieve  the  condition, 
while  in  body  wounds  in  which  internal  hemorrhage  is  going  on  we 
find  that  restoratives  avail  nothing.  The  fatality  on  the  field  of  battle 
to-day  is  greater  than  ever  before.  In  the  Civil  War  and  the  wars 
preceding  it,  the  average  of  deaths  to  the  number  of  wounded  stood 
as  1  to  4  1/2.  In  the  Manchurian  campaign  the  proportion  is  as  1  to 
3  1/2.  Doubltess  the  greater  fatality  arising  from  internal  hemorrhage 
after  rifle  wounds  is  one  of  the  factors  which  adds  to  the  battle  mor- 
tality of  the  present.  At  the  same  time  that  military  surgeons  agree 
that  the  fruitful  cause  of  death  on  the  field  comes  as  a  result  of  primary 
hemorrhage,  no  accurate  estimate  of  the  percentage  of  deaths  from  this 
cause  has  ever  been  made  for  the  reason  that  the  surgeons  are  gener- 
ally too  much  occupied  in  rendering  aid  to  the  wounded  to  devote 
any  time  to  the  dead. 

(d)  Thirst. — A  drink  of  water  is  one  of  the  first  requests  made  by 
men  wounded  in  battle.  Thirst  is  always  present  and  it  is  very  much 
aggravated  if  the  wounds  are  attended  with  hemorrhage.  The  fact 
that  this  symptom  is  more  apparent  in  soldiers  is  doubtless  due  to 
circumstances  which  often  precede  engagements,  such  as  (1)  forced 
marches  in  summer  with  few  opportunities  to  obtain  water;  (2)  sol- 
diers are  taught  to  abstain  from  drinking  because  of  the  ill  effects  that 
indiscriminate  drinking  of  water  has  on  the  endurance  of  men  on  the 
march;  (3)  exertion  and  loss  of  body  fluids,  perspiration,  loss  of  sleep 
which  induce  a  feverish  state;  (4)  the  ration  in  the  emergent  condi- 
tions of  active  campaign  is  usually  made  up  of  salt-meat  and  hard 
bread.  All  of  the  foregoing,  with  the  excitement  and  din  of  battle, 
combine  to  excite  the  nervous  system,  and  to  produce  thirst  in  the 
soldiery.  The  experienced  military  surgeon  is  always  on  the  alert 
for  means  to  provide  water  for  the  wounded,  and  among  the  many 
things  he  can  do  to  alleviate  suffering  this  is  one  of  the  most  merciful. 

1  Op.  cit. 


CHAPTER  IV 

1.  Infection  of  Gunshot  Wounds;  2.  Poisoned  Wounds;  3.  Tet- 
anus AND  Toy-pistol  Tetanus 

(1)  Infection  of  gunshot  wounds  has  to  do  with  the  following: 

(a)  Sectional  area  of  the  projectile. 

(b)  Source  of  infection. 

(c)  Constitutional  and  local  resistance. 

(d)  Virulence  of  microorganisms. 

(e)  Infection  of  wounds  bj^  modern  armament. 

(f)  Environment. 

(a)  Sectional  area  of  the  Projectile. — In  the  earlier  years  of  gun- 
making  the  projectiles  used  in  hand  weapons  were  of  large  caliber  and 
since  they  were  composed  of  soft  lead  the  tendency  for  such  bullets 
on  impact  against  resistant  structures  was  to  still  further  increase 
their  sectional  area.  The  wounds  that  were  thus  caused  possessed 
all  the  characteristics  that  favor  the  development  of  infection,  viz., 
hematoma,  contusion,  laceration,  etc.  Later,  the  lead  composing  the 
bullets  was  hardened  by  an  admixture  of  about  5  per  cent,  of  antimony. 
But  at  about  this  time  the  improvements  in  gunnery  added  greater 
velocity  and  energy  to  the  projectiles,  so  that  the  tendency  to  defor- 
mation when  the  bullet  collided  with  resistant  bone  was  still  marked, 
and  here  again  the  wounds  showed  those  characters  that  augment 
the  disposition  to  infection.  The  relation  between  the  original  sec- 
tional area  of  a  bullet  and  infection  have  always  been  marked  for  the 
reasons  mentioned,  and  it  is  a  matter  of  common  observation  that  it 
is  very  much  increased  when  the  projectile  flattens  or  disintegrates 
against  bone,  enough  to  disperse  fragments  in  various  directions.  In 
such  a  case  the  metallic  fragments  acting  as  secondary  projectiles 
cause  additional  laceration  of  tissue,  contusion  and  hematoma. 

In  recent  years  the  sectional  area  of  rfle  bullets  has  been  very  much 
reduced — from  .45  calibers  to  .30  and  even  less — and  the  influence 
of  lessening  the  sectional  area  has  resulted  in  marked  beneficence  in 
the  character  of  the  wounds.  Besides  lessening  the  sectional  area  and 
also  the  weight  of  bullets,  their  hardness  has  been  very  much  increased 
by  enveloping  the  lead  bullet  in  a  mantle  of  hard  steel.     The  tendency 

122 


INFECTION    OF   GUNSHOT   WOUNDS  123 

to  deform  on  the  part  of  these  compound  bullets  when  colliding  against 
the  bony  framework  is  very  much  reduced.  The  wounds — except 
at  proximal  ranges  on  hard  bones — show  fewer  of  the  characters  which 
formerly  added  so  much  to  the  development  of  infection.  Such  a 
bullet  produces  less  traumatism  in  soft  tissues,  it  perforates  the  joint 
ends  of  bones  and,  except  when  it  is  possessed  with  high  velocity  on 
impact  against  hard  bone,  it  is  apt  to  produce  a  wound  having  the 
nature  of  an  incised  wound  comparatively  free  from  the  characters 
which  lead  to  the  development  of  infection  as  already  pointed  out. 

(b)  Source  of  Infection. — A  gunshot  wound  may  become  infected 
in  various  wa3^s.  Infection  primarily  on  the  projectile  itself  may  be 
carried  into  the  wound,  because,  contrary  to  what  has  been  taught 
by  many,  it  has  been  amply  shown  that  the  act  of  firing  does  not  con- 
vey enough  heat  to  a  bullet  at  any  time  to  render  it  sterile.^  Granting 
that  a  bullet  is  sterile  at  the  time  of  firing,  it  can  gather  infection  by 
ricochet,  or  by  passing  through  intermediate  substances  and  thereby 
infect  a  wound.  Infection  is  nearly  always  carried  into  the  wound 
with  shreds  of  clothing,  the  amount  of  the  latter  usually  being  in  pro- 
portion to  the  sectional  area  of  the  bullet.  A  bullet  can  gather  in- 
fection from  a  dirty  gun-barrel,  and,  lastly,  the  skin  which  is  pierced 
or  punched  by  the  projectile  invariably  contains  infected  matter,  which 
is  carried  in  with  the  bullet.  The  foregoing  is  true  of  all  projectiles 
fired  from  hand  weapons,  including  the  most  perfect  of  the  high- 
power  militarj^  rifles  for  all  ranges,  at  least  from  near  the  muzzle  to 
500  yards,  as  we  have  actually  demonstrated  by  experiments  on  the 
target  range,  and  no  doubt  the  same  is  true  of  the  maximum  ranges 
for  all  hand  weapons. 

It  is  true  that  projectiles  are  sometimes  found  in  original  packages 
practically  sterile  and  free  from  septic  germs.  This  was  especially 
true  of  lead  bullets  that  were  lubricated  by  dropping  in  hot  boiling 
grease,  but  contamination  is  unavoidalbe  in  the  ordinary  act  of  handling 
and  loading,  so  that  it  is  safe  to  say  that  all  bullet  wounds  are  infected 
whether  they  show  any  marked  evidence  of  such  infection  in  a  clinical 
way  or  not.  A  gunshot  wound  is  certainly  never  bacteriologicallj' 
clean. 

(c)  Constitutional  and  Local  Resistance. — The  general  resistance 
of  soldiers  in  arduous  campaign  is  apt  to  be  lower  than  normal,  and 

1  Can  a  Septic  Bullet  Infect  a  Gunshot  Wound?  Xew  York  Medical  Journal, 
Vol.  LVI,  No.  17,  Oct.  22,  1892.  Septic  BuUets  and  Septic  Powders,  New  York 
Medical  Record,  Vol.  XVII,  No.  25,  June  22,  1895,  by  Louis  A.  La  Garde,  U.  S. 
Army. 


124  GUNSHOT   WOUNDS 

whatever  depresses  constitutional  resistance  in  the  way  of  privation 
and  hardship  is  apt  to  induce  susceptibility  to  the  development  of 
infection.  Local  resistance  is  largely  determined  by  the  mechanical 
effects  of  the  projectiles  causing  the  injury.  Microscopic  exami- 
nation of  the  soft  tissues  surrounding  the  channel  made  by  the  bullet 
shows  laceration,  hematomata,  and  contusion,  conditions  favoring 
coagulation  necrosis.  In  addition,  dispersion  of  extraneous  matter 
will  be  found,  driven  laterally  by  the  energy  of  the  projectile  into  the 
tissues  to  a  distance  of  17  mm.,  varying  with  the  velocity  and  sectional 
area  of  the  bullet.^  This  extraneous  matter  is  lodged  everywhere 
amid  tissues  wholely  or  partially  devitalized.  In  such  a  condition  the 
development  of  infection  will  be  in  keeping  with  the  amount  of  trau- 
matism and  the  virulency  of  the  organisms  which  have  found  access 
to  the  injured  part. 

(cl)  Virulence  of  Microorganisms. — ^Wh^n  dwelling  upon  the  lia- 
bility to  infection  in  gunshot  wounds,  one  should  always  bear  in  mind 
the  mechanical  effects  of  a  rapidly  moving  body  through  tissues,  other- 
wise it  is  difficult  to  understand  the  appearance  of  the  so-called  viru- 
lent infections  in  such  wounds,  as  compared  to  what  takes  place  in 
clean-cut  wounds  like  those  made  by  a  keen  knife  blade,  for  instance, 
where  there  is  no  destruction  of  tissue  about  the  seat  of  injury,  no 
opportunity  for  the  lodgement  of  extraneous  matter  or  the  presence 
of  hematomata,  contusion,  laceration,  etc.  Welch,  in  his  Shattuck 
lectures,^  states  that  infection  from  the  bacillus  aerogenes  capsulatus 
is  most  frequently  seen  in  compound  fractures,  and  next  in  gunshot 
wounds.  The  reason  for  this  is  at  once  apparent.  The  lesion  in  the 
two  kinds  of  wounds,  namely,  a  compound  fracture  and  a  gunshot 
wound,  is  very  similar  as  regards  the  features  favorable  to  the  develop- 
ment of  infection.  In  a  gunshot  wound  we  may  state  further  that  bone 
injury  is  not  essential  because  gunshot  wounds  of  soft  parts  still  possess 
the  features  necessary  for  the  development  of  the  virulent  infections 
at  least. 

In  preantiseptic  times  the  surgical  wards  of  all  hospitals  were 
cursed  by  the  ravages  of  pus-producing  microbes.  The  experience 
of  military  surgeons  was  particularly  distressing  in  this  regard.  In 
our   Civil   War,  septicemia,    pyemia,    osteomyelitis,    erysipelas,    and 

1  Mutter  Lecture. — Poisoned  Wounds  by  the  Implements  of  Warfare.  Journal 
of  the  American  Medical  Association,  April  11-18,  1903,  by  Louis  A.  La  Garde, 
Med.  Corps,  U.  S.  Army. 

2  Boston  Med.  and  Surg.  Jour.,  No.  4,  Vol.  CXLIII,  July  26,  1900. 


INFECTION    OF    GUNSHOT   WOUNDS  125 

hospital  gangrene  were  the  bane  of  all  hospitals  after  great  battles'. 
Instead  of  amelioration  taking  place  in  the  character  of  the  infections 
as  the  war  progressed,  the  tendency  to  their  development  in  the  most 
trivial  injuries  seemed  to  augment  with  the  duration  of  the  war. 
Those  surgeons  who  survived  to  witness  the  dawn  of  antiseptic 
surgery",  and  the  masterly  way  in  which  we  avoid  sepsis  in  wounds 
to-day,  look  back  on  their  practice  in  the  sixties  with  genuine  sorrow. 
Robert  F.  Weir,  who  commanded  the  general  hospital  at  Frederick, 
Maryland,  after  the  battle  of  Antietam,  while  commenting  on  the 
treatment  then  in  vogue,  has  made  the  following  statement.^  '^For, 
looking  backward,  the  surviving  surgeons  of  that  day  must  admit  that 
they  were  unwittingly  more  fatal  to  those  under  their  care  than  the 
battle  was;  that  death  followed  the  path  of  the  surgeon,  with  his 
poisonous  technique  and  dressings.  What  indeed  was  more  provoca- 
tive of  infection  than  the  care,  for  instance,  of  the  sponges  used  at  an 
operation?  These  were  used  repeatedly,  whether  for  clean  or  septic 
cases,  as  we  now  say.  Washed  repeatedly,  it  is  true,  in  fresh  water, 
but,  after  all,  germ-laden.  Kept,  too,  soaking  in  water  until  again 
required,  and  producing  millions  of  virulent  germs,  which,  by  the 
surgeons  act,  were  at  the  next  operation  smeared  freely  over  the 
wound.  The  Borgias  never  did  as  much!  Though  they  knew  what 
they  were  doing." 

This  is  a  painful  admission  and  yet  it  is  made  by  one  whose  life 
has  been  consecrated  to  the  relief  of  human  suffering,  one  of  America's 
greatest  surgeons.  We  now  know  that  the  surgeons  of  that  time 
passed  day  after  day  from  patient  to  patient  planting  and  trans- 
planting, year  in  and  year  out,  with  their  poisonous  technique,  septic 
organisms  from  wound  to  wound,  thus  adding  to  their  virulency  with 
the  duration  of  the  war  until  the  tissues  showed  a  tendency  to  sup- 
puration, slough,  and  the  development  of  a  gangrene  which  was  then 
called  hospital  gangrene,  the  etiology  of  which  is  unknown  and  which 
only  ceased  to  make  its  appearance  about  the  time  the  war  was  ended. 
In  addition  to  the  virulence  of  the  organisms  that  had  been  developed 
with  time,  the  surgeons  of  that  day  dealt  with  gunshot  wounds  by  the 
rifles  of  .55  to  .70  calibers,  the  projectiles  were  made  of  soft  lead 
weighing  450  to  760  grains,  and  they  were  animated  with  a  velocity 
of  about  1200  f.s.  Wounds  from  such  missiles  were  attended  with 
extreme  traumatism  and  the  shells  and  canisters  of  the  times  were  still 

^  Remarks  on  Gunshot  Wounds  of  the  Civil  War,  by  Robert  F.  Weir,  M.  D., 
N.  Y.  State  Journal  of  Medicine,  1904,  No.  4,  pp.  141. 


126  GUNSHOT    WOUNDS 

worse  in  their  destructive  effects,  so  that  everything  in  that  era, 
the  character  of  the  wounds,  the  virulency  of  the  microbes,  and  the 
ignorance  of  the  surgeons,  seemed  to  combine  in  adding  to  the  horror 
of  the  situation. 

(e)  Infection  of  Wounds  by  Modern  Armament. — Infection  in  war 
wounds  with  present-day  armament,  broadly  stated,  varies  in  fre- 
quency and  extent  with  the  character  of  the  missile  which  inflicts  them. 
Shells  and  shell  fragments  cause  wounds  attended  with  infection  in 
modern  wars  as  much  as  they  did  formerly.  Wounds  from  this 
source  require  the  unremitting  care  of  the  surgeon  to  arrest  or  curtail 
the  infection  which  is  invariably  present.  Hand-grenades,  bombs, 
mines  and  pom-pom  shells  inflict  lacerated  and  contused  wounds 
which  invariably  suppurate  when  the  wound  is  of  any  magnitude. 
The  shrapnel  balls  cause  wounds  that  suppurate  as  a  rule.  The  ball 
is  round,  .50  calibers  in  diameter,  composed  of  lead,  weighing  fron  167 
to  288  grains.  The  contusion,  laceration  and  hematoma  which  it 
invariably  inflicts  in  the  wound  channel  adds  specially  to  the  chances 
of  infection.  Modern  rifle-bullet  wounds  exhibit  less  tendency  to 
suppuration.  The  projectile  from  the  reduced  caliber  rifle  now 
carried  by  foot  and  mounted  troops  is  about  .25.6  to  .30  calibers. 
It  is  made  up  of  a  core  of  lead  encased  in  an  envelope  of  hard 
steel,  the  whole  bullet  weighing  from  150  to  220  grains.  This 
bullet  has  caused  the  majority  of  wounds  in  recent  wars  and  we  find 
that  wounds  inflicted  by  it  are  for  the  most  part  apt  to  be  humane 
and  that  they  are  prone  to  heal  with  but  little,  and  at  times  apparently 
no  suppuration.  Still  if  one  takes  pains  to  carefully  examine  the 
tissues  under  the  scab  covering  the  wound  of  exit  especially,  he  will 
generally  find  pus  in  wounds  that  are  healing  aseptically  in  the  opinion 
of  many  surgeons.  The  wound  of  exit  is  generally  larger  than  the 
wound  of  entrance,  more  lacerated,  and  the  seat  of  this  traumatism 
being  in  a  dirty  skin  affords  all  the  necessary  opportunities  for  infec- 
tion. In  the  Santiago  campaign  infection  of  the  wound  of  exit  from 
the  Spanish  Mauser  bullet  was  the  rule.  In  ricochet  shots  of  soft 
parts  showing  irregular  impact,  suppuration  was  very  prone  to  occur. 
Rifle-ball  wounds  attended  with  fracture  of  the  long  bones  showed 
tendency  to  suppuration  in  proportion  to  the  amount  of  comminu- 
tion, the  size  of  skin  wounds,  and  attendant  lacerations.  Such 
wounds  suppurated  in  spite  of  the  proper  application  of  the  first 
dressing.  Doubtless  they  would  have  had  more  chance  for  the 
introduction   of   additional   infection   without   protection   from   the 


INFECTION    OF    GUNSHOT   WOUNDS  127 

clean  dressing,  yet  if  a  virulent  infection  had  entered  such  a  wound 
with  the  projectile,  the  first-aid  dressing  could  have  remained  of  no 
avail  to  prevent  the  subsequent  clinical  history  of  such  an  infection, 
notwithstanding  the  oft-quoted  saying  of  Prof,  von  Nausbaum  that 
'Hhe  fate  of  the  wounded  rests  in  the  hands  of  the  one  who  applies 
the  first  dressing."  When  one  considers  that  the  rifle  bullets  which 
inflict  wounds  in  modern  wars  are  carried  in  dirty  bandoliers  and 
handled  by  dirty  hands,  that  they  are  not  sterilized  by  the  act  of  firing, 
it  should  be  the  exception  to  find  a  wound  in  which  healing  takes 
place  by  first  intention.  When  it  does,  it  is  because  the  wound  is 
simple,  in  soft  parts,  through  tissues  having  a  well-developed  local 
resistance,  and  not  because  the  projectile  is  in  any  way  sterile. 
Of  the  1400  wounded  in  the  Santiago  campaign  none  of  the  virulent 
infections  were  noted,  extensive  suppuration  from  the  ordinary  pus- 
producing  microbes  was  not  often  seen,  and  it  was  always  easily  con- 
trolled. The  absence  of  severe  infections  has  been  very  properly 
attributed  to  the  wide  use  of  the  first-aid  dressings  carried  by  the 
soldiers  and  menbers  of  the  relief  corps  on  the  line.  The  improper 
application  of  these  dressings,  as  shown  by  the  way  in  which  they 
became  loose  and  failed  adequately  to  protect  the  wounds  to  which 
they  were  applied,  when  examined  at  the  Base  Hospital  at  Siboney, 
demonstrated  conclusively  that  there  were  other  factors  which 
assisted  in  preventing  suppuration.  The  battle  was  fought  on  the 
first  of  July  in  a  tropical  climate  by  an  army  that  was  embarked  two 
weeks  before  at  Tampa,  Florida.  Because  of  the  overcrowded  con- 
dition of  the  ships  the  Medical  Department  insisted  on  daily  baths 
to  the  men.  They  were  placed  under  the  hose  at  certain  hours,  so 
that  their  skins  were  clean  on  landing.  Khaki  was  the  uniform,  and 
the  rainy  season  had  set  in,  so  that  the  air  was  washed  of  dust  daily 
by  afternoon  showers.  The  foregoing  and  the  small  frontage  of  the 
Mauser  bullet  of  the  Spaniards,  which  carried  but  few  shreds  of 
clothing  into  the  wounds,  contributed  largely  no  doubt  to  lower  the 
percentage  of  severe  infections. 

Antisepsis  and  the  use  of  projectiles  of  the  reduced  caliber  rifle 
have  combined  to  bring  about  marked  beneficence  in  the  war  wounds 
of  modern  times.  In  the  Civil  War  the  mortaliity  among  those  who 
reached  the  hospitals  was  14.3  per  cent.  From  the  same  class  of 
cases  the  mortality  was  6  per  cent,  in  the  Spanish-American  War, 
8  per  cent,  in  the  Boer  War,  and  in  the  Russo-Japanese  War  it  was 
5.8  per  cent,  on  the  Japanese  side  and  3.4  per  cent,  on  the  Russian 


128  GUNSHOT    WOUNDS 

side.  The  material  reduction  in  the  mortahty  since  the  Civil  War,  as 
ah'eady  stated,  is  doubtless  the  result  of  the  use  of  antisepsis  and  the 
change  in  the  armament. 

The  results  of  Carl  Reyher  and  von  Bergmann,  who  were  the  first 
to  employ  antiseptic  methods  in  military  surgery  in  the  field  during  the 
Russo-Turkish  War  of  1877-78  in  wounds  of  the  knee-joint,  point 
strongly  to  the  value  of  this  mode  of  treatment  in  active  campaign,  and 
our  results  in  the  Spanish- American  War  bear  as  forciblj^  in  favor  of 
the  humane  projectile  in  wounds  of  the  same  bodily  region.  In  the 
Russo-Turkish  War  the  rifles  of  the  combatants  corresponded  to  the 
.45  caliber  Springfield  which  we  discarded  in  1892.  The  500-grain  lead 
bullet  having  a  velocity  of  1301  f  .s.  caused  great  laceration  of  j  oints  and 
epiphyseal  ends.  Up  to  the  time  of  the  happy  results  published  by 
Rejdier  and  von  Bergmann  the  older  surgeons  unanimously  practised 
amputation  as  the  sole  method  of  treatment  in  gunshot  wounds  of 
the  knee-joint.  This  was  the  practice  in  the  Crimea  and  that  of  the 
surgeons  in  our  great  Civil  War  and  it  was  employed  to  cut  short  the 
ravages  of  sepsis.  Reyher  reports  eighteen  cases  of  wounds  of  the 
knee  treated  antiseptically,  regardless  of  the  extent  of  joint  involve- 
ment, of  whom  three  died,  a  mortality  of  16.6  per  cent.  The  treat- 
ment was  strictly  conservative  without  excision  or  amputation.  The 
cases  ending  in  recovery  are  said  to  have  had  movable  joints.  He 
employed  irrigation  in  severe  cases,  while  the  more  simple  cases  were 
cleansed  externally  and  dressed  with  wet  carbolic  gauze.  Von  Berg- 
mann employed  the  same  method  of  treatment  with  the  following 
results:  Out  of  fifteen  gunshot  fractures  of  the  knee,  fourteen  re- 
covered in  three  of  whom  amputation  was  required.  The  fatal  case 
was  one  of  those  in  which  amputation  was  practised.  Nothing  is 
said  of  the  amount  of  motion  remaining  in  the  non-amputated  cases. 
The  majority  of  them  more  than  likely  got  well,  as  did  those  of  Rey- 
her with  movable  joints.  The  cases  treated  by  Reyher  and  von  Berg- 
mann occurred  before  the  change  in  the  armament  of  the  nations  had 
taken  place.  They  represent,  therefore,  the  results  of  injuries  by  the 
old  soft  leaden  bullet  of  .45  caliber,  weighing  approximately  480  grains, 
treated  conservatively  under  antiseptic  methods.  Grouped  together 
we  find  that  the  mortality  was  for  the  two  sets  of  cases  only  11.1  per 
cent.  Compared  to  the  results  of  treatment  of  gunshot  injuries  by 
the  old  arm  in  the  preantiseptic  era  the  results  of  Reyher  and  von  Berg- 
mann were  certainly  a  revelation.  In  looking  over  the  statistics  given 
us  by  Otis,  we  find  that  gunshot  wounds  of  the  knee  in  the  Civil  War 


INFECTION    OF    GUNSHOT   WOUNDS  129 

under  all  methods  of  treatment  then  in  vogue  gave  a  mortalitj^  of  53.7 
per  cent.,  which,  compared  to  the  results  of  Reyher  and  von  Bergmann, 
places  to  the  credit  of  antisepsis  a  total  of  42.6  lives  saved,  in  every 
100  men  hit  in  the  knee. 

In  late  years  changes  have  come  about  in  the  manufacture  and  com- 
position of  rifle  bullets  to  enhance  the  satisfactory  results  already 
alluded  to,  both  as  to  life  and  limb.  The  character  of  gunshot  wounds 
of  bones  especially  is  veiy  much  influenced  by  the  density  of  the 
metals  which  inflicts  them.  Longmore,^  among  older  "^Titers,  ventured 
to  explain  thirty-five  years  ago  what  would  be  the  special  features  of 
gunshot  wounds  as  soon  as  it  became  practicable  to  use  steel  bullets. 
The  evolution  of  the  military  rifle  and  the  missile  it  propels  to-day  have 
given  us  factors  which  in  a  humane  sense  stand  next  in  importance 
to  antisepsis. 

The  following  table  shows  at  a  glance  the  successive  results  of 
gunshot  wounds  of  the  knee  from  the  clays  of  the  Civil  War  to  the 
present  time. 

GUNSHOT   WOUNDS   OF   THE  KNEE-JOINTS 

CIVIL  WAR,  1861-1865 
Large  Calibers  minus  Antisepsis 

Mortality 53.7  per  cent. 

Recovery 46.3  per  cent. 

Fit  for  duty 00.0  per  cent. 

Total 100.0  per  cent.       Unfit  for  duty 100.0  per  cent. 

RUSSO-TURKISH  WAR  1877-1878 

33  CASES  BY  Reyher  and  vox  Bergmann 

Large  Caliber  plus  Antisepsis 

Mortality 11.1  per  cent. 

Recovery 88 . 9  per  cent. 

Fit  for  duty 00.0  per  cent. 

Total 100.0  per  cent.      Unfit  for  duty 100.0  per  cent. 

REPORT  SURGEON-GENERAL,  U.  S.  ARMY,   1898-1902 

76  cases 

Various  Calibers  plus  Antisepsis 

Mortality 6.5  per  cent. 

Recovery 93 . 5  per  cent. 

Fit  for  duty 39.4  per  cent. 

Total 100.0  per  cent.      L'nfit  for  dity 60.6  per  cent. 


Total 100.0  per  cent. 

^  Gunshot  Injuries,  by  Sir  Thomas  Longmore. 


130  GUNSHOT   WOUNDS 

SANTIAGO  CAMPAIGN,  1898 

17  CASES 

Reduced  Caliber  plus  Antisepsis 

Mortality 00.0  per  cent. 

Recovery 100 . 0  per  cent. 

Fit  for  duty 81 . 1  per  cent. 

Total 100.0  per  cent.      Unfit  for  duty 18.9  per  cent. 

Total 100.0  per  cent. 

To  Recapitulate. — (1)  We  find  that  the  mortality  of  gunshot  injury 
of  the  knee-joint  in  the  Civil  War  was  53.7  per  cent.,  and  as  amputa- 
tion was  universally  done,  all  those  who  recovered  escaped  with  the 
loss  of  a  limb,  unfit  for  duty;  (2)  that  thirty-three  cases  of  gunshot 
wounds  of  the  knee  produced  by  the  larger  caliber  lead  bullet  in 
campaign,  reported  by  Reyher  and  von  Bergmann,  treated  antisepti- 
cally,  gave  a  mortality  of  11.1  per  cent.;  (3)  that  76  cases  produced 
by  a  variety  of  missiles  reported  by  the  Surgeon-General  1898-1902, 
similarly  treated,  gave  a  mortality  of  6.5  per  cent,  and  that  39.4  per 
cent,  of  those  who  recovered  were  restored  to  duty;  (4)  that  of  seven- 
teen cases  in  the  Santiago  campaign  by  the  reduced-caliber  bullet  the 
mortality  was  nil,  and  that  81.1  per  cent,  of  the  wounded  recovered 
fit  for  duty.  It  is  thus  seen  that  the  humane  features  of  the  reduced 
caliber  bullet  have  operated  not  only  in  diminishing  the  mortality 
in  gunshot  injuries  of  the  knee  from  about  6.5  per  cent,  to  nil,  but  that 
it  has  increased  restorations  to  duty  41.7  per  cent,  as  shown  by  com- 
paring the  last  two  tables. 

According  to  Stevenson  the  observers  in  the  Boer  War,  both  civil 
and  military,  report  that  wounds  with  the  exception  of  compound 
fractures  were  wonderfully  free  from  suppuration,  "and  that  when 
it  did  occur  it  was  only  in  a  minor  degree  and  that  it  seldom  gave 
rise  to  general  septic  infection  but  only  caused  more  or  less  delay 
in  convalescence."  Havard  and  Follenfant,  with  the  Russian 
army  in  Manchuria,  dwell  on  the  frequency  of  infection  of  wounds  by 
the  Japanese  rifle,  which  employs  a  projectile  .256  inches  in  cahber, 
weighing  152  grains.  Havard  places  the  number  of  [infections  at 
10  per  cent,  in  the  summer,  and  90  per  cent,  in  the  winter.  Follen- 
fant says  that  50  per  cent,  became  infected  in  summer  and  80  per 
cent,  in  winter.  (Reyher^  has  noted  this  point  not  only  for  the 
Manchurian    campaign   but   for    all   gunshot    wounds    occurring   in 

1  Reyher,  Dr.  W.  V.,  Vol.  LXXXVIII,  .4rchiv.  fur  Klinische  Chirurgie  1908-9. 


INFECTION    OF   GUNSHOT   WOUNDS  131 

winter  because  of  the  extra  amount  of  clothing  worn.)  All  shrapnel 
wounds  were  infected.  Follenfant  states  that  compared  to  the  infec- 
tions with  the  11-mm.  leaden  bullet,  which  corresponds  to  our  .45- 
caliber  Springfield  leaden  bullet,  weighing  500  grains,  those  by  the  small 
jacketed  bullet  are  possibly  not  quite  as  frequent,  they  are  more  tardy 
to  develop,  more  localized  and  less  grave.  Abscesses  were  not  so 
frequent,  febrile  reaction  not  so  intense,  erysipelas  more  rare,  and 
recovery  after  suppuration  was  more  prompt.  Death  from  septicemia 
was  seldom  seen,  and  he  saw  but  one  case  of  gas-bacillus  infection, 
from  a  shrapnel  wound  of  the  thigh  with  a  lodged  fragment  four  days 
after  the  injur}'.  The  f requeue}^  of  infection  in  the  cold  months  is 
attributed  to  the  heavy  clothing  worn  by  the  Russian  soldier,  including 
a  sheepskin  overcoat.  Extraneous  matter  was  thus  carried  into  the 
wounds  by  the  force  of  the  bullet  against  a  dirty  skin  when  the  oppor- 
tunity for  bathing  was  not  at  hand.  Major  Charles  Lynch,  our  ob- 
serverwith  the  Japanese  army,  places  the  tendency  to  suppuration  of 
wounds  in  soft  parts  by  the  Russian  rifle  bullet  at  60  per  cent.  "  All 
rifle-bullet  wounds  with  bone  involvement  suppurated.  The  tendency 
to  suppuration  of  wounds  in  any  tissue  by  the  Russian  bullet  was 
thought  greater  than  that  found  in  wounds  by  the  Japanese  bullet  and 
the  reason  is  ascribed  to  the  larger  caliber  of  the  former.  Wounds  by 
shrapnel,  shell  fragments,  bombs,  hand  grenades,  and  deformed  rifie 
bullets  invariably  suppurated." 

(f)  Environment. — Infection  in  gunshot  wounds  is  apt  to  occur  in 
proportion  to  the  disturbance  to  which  the  wounded  are  subjected. 
In  military  practice  enforced  transport  complicates  the  results  of 
wound  treatment  materially.  After  great  battles  there  is  usually 
insufficient  relief  personnel;  the  wounded  lie  unattended  for  hours  in 
varying  conditions  of  weather  and  temperature.  Gunshot  injuries 
to  bones  and  joints,  which  need  absolute  rest,  are  not  always  properly 
immobilized.  Lengthy  transport  under  such  conditions  in  springless 
wagons  over  bad  roads  adds  much  to  the  probability  of  infection. 

(2)  POISONED  WOUNDS 

This  is  a  subject  so  nearly  related  to  wound  infection  that  it  can 
very  properly  be  treated  in  this  chapter.  Reference  to  poisoned 
wounds  is  frequent  in  the  literature  of  wounds  by  firearms.^  The 
practice  of  poisoning  implements  of  warfare  like  the  spear,  sword, 

1  The  Mutter  Lecture  by  the  author,  op.  cit. 


132  GUNSHOT   WOUNDS 

arrowheads,  knives,  javelins,  etc.,  dates  back  to  the  days  of  the  Greeks 
and  Romans.  A  practice  that  is  abhorred  to-day  and  classed  among 
the  most  cowardly  deeds  in  the  list  of  crimes  seems  to  have  been  pretty 
generally  adopted  in  ancient  times.  Poisoned  arrows  were  used  by 
the  ancients  against  man  and  beast.  The  Celts  in  the  hunt  poisoned 
their  arrowheads  with  a  substance  which  was  called  toxic.  After 
wounding  a  deer,  for  instance,  the  seat  of  injury  was  excised  at  once 
to  prevent  rapid  decomposition.  They  also  used  hellebore  and  a 
substance  called  limeum  which  was  known  as  deer  posion.  The 
Vandals  who  inhabited  what  is  now  North  Germany  used  various 
poisons,  aconite  being  the  most  deadly,  and  Claude  Bernard  states 
that  the  practice  of  poisoning  missiles  was  employed  in  more  recent 
times  and  in  the  Spanish  Army  as  late  as  the  reign  of  Phillipe  the 
third.  Some  of  the  poisons,  like  curare,  were  said  to  cause  death 
when  introduced  through  a  wound  and  they  remained  innocuous  when 
ingested  per  os.  Of  the  vegetable  poisons  most  commonly  employed, 
mention  is  made  of  extract  of  hellebore,  aconite,  yew,  limeum,  ninum, 
helenium.  The  nature  of  the  last  three  of  these  is  unknown  to  us.  In 
this  regard  we  may  state  that  if  ail  that  is  written  of  the  lethal  char- 
acter of  some  of  the  poisons  used  is  true,  the  ancients  were  past- 
masters  in  the  practice  of  what  is  to  us  a  lost  art. 

Among  animal  poisons  used  in  modern  times  to  poison  missUes 
and  cutting  weapons  for  the  hunt  and  in  warefare  by  savage  tribes  in 
Africa,  the  South  Seas,  India,  and  China,  may  be  mentioned  decom- 
posing viscera,  and  snake  venum.  Anthrax  and  curare  are  used  by 
tribes  in  West  Africa  and  the  tropical  water-ways  of  the  Amazon 
respectively.  The  inhabitants  of  New  Caledonia  infect  their  arrow- 
heads by  dipping  them  in  crab  holes,  and  the  experiments  of  Ledantec^ 
showed  that  animals  inoculated  with  the  poison  some  months  after 
the  preparation  of  the  arrowheads  die  of  either  tetanus  or  malignant 
edema,  but  more  often  the  latter. 

Our  North  American  Indians  poisoned  arrowheads  and  bullets  in 
a  more  varied  but  less  deadly  manner.  The  poisoning  of  the  war 
implements  was  more  often  done  during  a  period  of  self-torture  and 
fasting  by  the  young  warriors  during  a  war  dance  or  a  religious  cere- 
mony. The  Comanches  are  said  to  have  used  the  juice  of  the  Spanish 
bayonet.  The  vSipares  used  the  menstrual  blood  of  a  woman,  while 
the  Apaches  prepared  their  poison  by  grinding  the  heads  of  rattlesnakes 

1  Origine  Tellurique  du  poison  des  fleches  des  Naturels  des  Nouvelles  Hebrides 
(Oceanie),  Archives  de  Med,  Nor.  et  Col.,  1893. 


INFECTION    OF    GUNSHOT   WOUNDS  133 

with  fragments  of  deer  liver.  The  Moqui  Indians  irritate  a  rattle- 
snake to  the  point  of  madness.  At  this  time  it  inflicts  stings  in  its 
own  body  and  the  high  priest  of  the  Order  of  Snakes  dips  the  arrow 
points  or  bullets  in  the  bloody  fluid.  The  poison  thus  prepared  is 
said  to  cause  death  in  three  days. 

Our  own  work  with  septic  bullets  and  septic  powders^  has  shown 
that  microorganisms  placed  on  projectiles  or  on  powder  grains  are 
not  destroyed  by  the  act  of  firing.  We  fired  bullets  from  different 
kinds  of  hand  weapons  which  were  previously  contaminated  with 
anthrax  germs  into  susceptible  animals  at  varying  distances  up  to 
500  yards  and  the  animals  died  of  anthrax  in  the  majority  of  the  cases. 
We  also  experimented  with  vegetable  poisons,  viz.,  curare  and  ricin, 
the  latter  being  the  most  deadly  of  the  vegetable  poisons,  and  our 
experiments  confirmed  what  appears  in  the  literature,  viz.,  the 
possibility  of  conveying  poisons  of  any  kind  to  man  or  beast  by  shooting. 

Follenfant  makes  note  of  the  frequency  of  malignant  pustule 
among  Russian  soldiers  seen  in  the  hospitals  in  Mukden  in  the  Russo- 
Japanese  War,  which,  in  a  negative  way,  is  of  interest  on  the  subject 
of  wound  infection.  Cases  were  carried  to  the  hospitals  daily  in 
January,  1905,  The  infection  was  attributed  to  imperfect  tanning 
of  the  sheepskins  from  which  their  overcoats  had  been  manufactured, 
the  animals  having  died  of  peste  siberienne.  No  case  of  wound  in- 
fection showing  the  septicemic  form  of  anthrax  was  observed,  and  yet 
the  spores  of  the  organism  were  doubtless  carried  into  the  wounds  by 
the  projectiles.  In  connection  with  our  experiments  with  anthrax 
balls  on  animals,  already  qouted,  the  observations  of  Follenfant  are 
very  interesting.  The  Manchurian  campaign  points  in  this  regard 
to  a  fact  already  appreciated,  namely,  that  man  is  not  susceptible 
like  some  of  the  lower  animals  to  the  septicemic  form  of  anthrax. 
His  susceptibility  is  only  skin  deep,  as  it  were,  hence  the  malignant 
pustule.  The  latter  no  doubt  arose  from  infection  of  abraded  sur- 
faces on  the  skin  of  soldiers  wearing  the  infected  sheep-skin  overcoats. 

(3)  Tetanus  and  Toy-pistol  Tetanus 

This  disease  should  have  been  considered  with  the  virulent  infec- 
tions, but  its  history  is  so  well  identified  with  gunshot  wounds  in 
peace  and  war;  its  definite  clinical  symptoms  and  marked  virulency 
for  certain  lower  animals  have  made  it  of  such  value  to  experiment- 

^  Mutter  Lecturer  op.  cit. 


134 


GUNSHOT   WOUNDS 


ers;  and,  lastly,  under  the  term  toy-pistol  tetanus  it  occupies  such  a 
unique  place  in  American  literature  that  it  deserves  extended  consid- 
eration, by  itself. 

The  frequency  of  tetanus  in  war  wounds  has  been  attested  by  many 
writers.  The  following  table  from  Nimier  and  Laval  by  Mathieu 
shows  its  occurrence  in  a  number  of  the  great  wars,  the  general  average 
being  about  one  case  of  tetanus  in  every  300  wounded. 


TABLE  4.— TETANUS  IN  WAR  (BY  MATHIEU) 


Wars 


Cases  of 
tetanus 


No.  of 
wounded 


Percentage 


British  Army  in  India  (1782) 

British  Army  in  Spain  (1811-14) 

British  Army  in  Crimea 

Spanish    Army    in    Morocco,    wounded 

cared  for  in  Africa. 
Spanish    Army    in    Morocco,    wounded 

cared  for  in  Spain. 

French  Army  in  Cairo  (1798) 

French  Army  before  Constantinople(1836) 

French  Army  in  Crimea 

French-Sardinian  Hospitals  (1859) 

Prussian  Army  (1864) 

Hanoverian    Army    after    Langensalza 

(1866). 

German  Army  (1870-71) 

Austrian  Army  in  Bosnia  (1878) 

United  States  Army,  Civil  War 


20 

263 

26 

1 


810 

20,683 

12,094 

56 


1/40  or  2.47 
1/78  or  1.25 
1/465  or  0.21 
1/56    or  1.78 


4 

3,920 

1/980  or  0.10 

7 

200 

1/28  or  3.50 

10 

176 

1/17  or  5.68 

120 

39,868 

1/332  or  0.30 

153 

21,967 

1/143  or  0.69 

14 

1,968 

1/140  or  0.71 

13 

1,092 

1/84  or  1.20 

350 

99,566 

1/285  or  0.35 

16 

3,878 

1/234  or  0.41 

500 

246,712 

1/488  or  0.20 

In  more  modern  times  Schjerning,  inspector  general  of  the  German 
Armj',  collected  thirty-four  cases  of  tetanus  occurring  in  the  German 
Army  from  1881  to  1902  from  wounds  inflicted  by  blank  cartridges. 
Bonnette^  reports  six  cases  in  the  French  Army  from  the  same  class  of 
wounds  between  the  years  1892  and  1905.  The  blank  ammunition  of 
the  German  and  the  majority  of  continental  armies  is  provided  with 
a  hollow  wooden  projectile,  the  others  have  a  cardboard  projectile 
simular  to  that  in  our  armv. 


1  Bonnette,  j\Iedecin  Major,  etc..  Dangers  des  Tirs  a  Blanc,  Paris,  1907. 


INFECTION    OF   GUNSHOT   WOUNDS  135 

Deubler^  records  twentj'  cases  of  tetanus  in  Maneuvers  of  the 
Austrian  Army.  Of  this  number  seventeen  occurred  from  accidental 
gunshot  wounds  by  blank  cartridges  loaded  with  smokeless  powder. 
The  author  points  out  the  increase  of  tetanus  since  the  introduction 
of  the  new  explosive,  but  he  attributes  it  to  the  wadding,  which  is 
larger  and  more  carefully  packed  in  smokeless  powder  cartridges  to 
insure  a  louder  report,  the  object  being  to  simulate  the  conditions  in 
war.  Examination  of  the  wads  showed  contamination  but  it  is  not 
stated  that  tetanus  spores  were  found.  As  we  will  show  later  the 
source  of  infection  was  most  probabty  not  in  the  ammunition.  We 
beheve  it  would  be  more  correct,  in  view  of  recent  investigations,  to 
attribute  the  occurrence  of  tetanus  in  these  cases  to  special  features 
in  the  lesion  conferred  bj^  the  explosive  as  well  as  by  the  wad,  and  to 
take  for  granted  that  the  source  of  infection  was  infected  dirt  in  the 
gun  barrel,  the  clothing,  or  the  skin  at  the  point  of  impact. 

The  humane  character  of  the  wounds  produced  bj-  reduced  caliber 
bullets  have  led  some  writers  to  suggest  that  there  would  be  fewer 
cases  of  tetanus  in  future  wars.  This  would  doubtless  be  true  if  the 
wounds  were  entirely  produced  by  projectiles  from  the  hand  rifle. 
Unfortunately  other  implements  which  cause  wounds  attended  with 
hematoma,  laceration,  contusion,  etc.,  such  as  grenades,  bombs,  shrap- 
nel, pom-pom  shells,  and  shell  fragments,  figure  in  the  battle  casualties 
of  the  present  day,  and  they  will  no  doubt  add  to  the  opportunity  for 
the  appearance  of  tetanus  among  the  wounded  hereafter.  Follenfant's 
observations  in  the  ]\Ianchurian  campaign  on  this  point  are  of  interest. 
He  tells  us  that  among  the  virulent  infections  tetanus  Avas  the  most 
frecjuent.  There  were  about  three  hundred  cases  with  a  mortality 
of  80  per  cent,  following  the  battle  of  Mukden,  due  it  is  said  to  poor 
transport  facilities,  and  more  especially  to  clouds  of  dust  the  last  three 
days  of  battle.  In  the  same  campaign  McPherson-  also  reports  the 
tendency  to  the  development  of  tetanus  and  malignant  edema  in 
wounds  resulting  from  the  destruction  of  bomb-proof  shelters,  espe- 
cially those  caused  by  splinters  of  the  beams  that  support  the  earth 
sheltering.  The  common  infections  were  also  frequent  in  such  wounds. 
He  states  further  that  infection  of  wounds  by  the  non-virlent  microbes  in 
the  army  besieging  Port  Arthur  was  more  common  than  in  those  of  the 
field  armies,  but  tetanus  was  mostly  seen  at  Mukden.  The  number  of 
animals  with  the  mobile  army  doubtless  contributed  to  contamination 

^  Verwundengofahigkeit  der  exercier-schusse  ^^littheilungen  tiber  Gregen- 
stande  des  Artillerie  und  Genie-Wessens. 

-  The  Russo-Japanese  War,  by  Lieut.-Col.  W.  G.  McPherson,  R.  A.  M.  C. 

10 


136  '  GUNSHOT   WOUNDS 

of  the  ground  over  which  the  army  was  constantly  on  the  move :  The 
favorite  habitat  of  the  bacillus  of  tetanus,  as  we  know,  is  the  intestinal 
track  of  the  herbivora. 

We  are  indebted  to  certain  experimenters  for  our  knowledge  of 
the  manner  in  which  tetanus  has  become  so  intimately  associated 
with  the  traumatism  of  a  gunshot  wound.  The  results  of  experiments 
by  Lwowitch,  Strick  and  Dorst^  show  conclusively  that  hematomata 
augment  the  susceptibility  to  infection.  They  injected  tetanus  in 
hematomata  produced  in  rabbits  by  destroying  the  femoral  artery 
subcutaneously  with  needles.  By  graduating  the  dose  so  injected 
it  was  found  that  compared  to  the  amount  necessary  to  produce 
lethal  effects  in  a  clean  incised  wound  hematomata  augmented  the 
susceptibility  one  thousand  fold.  In  regard  to  the  susceptibility 
conferred  by  hematomata  and  the  lesions  in  gunshot  wounds,  Strick 
found  that  the  latter  conferred  greater  susceptibility,  and  that  the 
onset  of  symptoms  in  animals  shot  with  tetanus  balls  is  twice  as 
rapid  and  death  ensues  earlier,  due  no  doubt  to  the  presence  of  hema- 
tomata and  the  state  of  devitalized  tissues  in  and  around  the  channel  of 
a  gunshot  wound. 

Toy-pistol  Tetanus. — In  this  country  the  frequent  occurrence  of 
tetanus  in  men  and  boys  who  amuse  themselves  in  celebrating  the  an- 
niversary of  our  National  Independence  by  the  use  of  explosives  in  toy- 
pistols,  fire  crackers,  torpedoes,  etc.,  has  called  forth  renewed  attention 
to  the  source  of  this  infection.  The  majorty  of  the  cases  have  arisen 
from  wounds  by  the  toy-pistol,  a  .22-caliber  revolver  carrying  six  blank 
cartridges,  loaded  with  an  average  of  six  grains  of  black  powder,  held 
in  place  by  a  paste-board  wad.  A  study  of  the  cases  shows  that  they 
are  grouped,  as  to  time,  about  July  fourth.  Now  that  some  of  the 
state  legislatures  have  prohibited  the  use  of  the  top-pistol,  the  yearly 
number  of  cases  is  not  so  large  as  formerly.  The  boards  of  health  of 
New  York  City  and  Chicago  in  three  years  time  have  recorded  as 
many  as  158  deaths,  and  as  many  as  400  deaths  from  tetanus  have 
occurred  for  the  whole  of  the  United  States  in  the  course  of  one  j^ear. 
Health  reports  from  a  number  of  the  cities  show  that  35  per  cent,  of 

1  Dorst:  Over  den  invloed  vanshet  hsematoom  op  het  cptreden  van  infectie 
in  die  chirurgie.  Ned.  Tijdschrift  voor  Genees-kunde,  1896,  2.  R.,  XXXII,  2 
afd.,  503-523. 

Lwowitch  (pupil  of  Kocher) :  unpublished  work  described  by  Tavel  in  Revue 
de  Chirurgie,  1899,  XIX,  pp.  701-702. 

Strick:  Die  Tetanusinfection,  von  Schusswunden  und  Hsematomen  ausge- 
hend  bei  Kaninchen  mit  besonderer  Berucksichtigung  der  Serum-Prophylaxis  und 
Therapie.     Inaug.  Dissertation  (Berne,)  Cologne,  1899. 


INFECTION    OF    GUNSHOT   WOUNDS  137 

the  cases  have  occurred  in  the  month  of  July  and  that  41  per  cent, 
of  the  cases  have  come  from  toy-pistol  wounds. 

The  source  of  tetanus  in  wounds  by  blank  ammunition  was  care- 
fully studied  by  a  number  of  observers.  The  work  was  directed  toward 
the  bacteriology  of  the  powder  and  wads  by  means  of  culture  methods 
and  inoculations  into  aniamls.  The  powder  was  examined  for  acci- 
dental contamination,  and,  because  so  many  observers  had  ascribed 
the  introduction  of  the  poison  by  the  wad,  we  undertook  a  careful 
investigation  of  the  possible  contamination  from  this  source.  Al- 
though we  found  that  the  process  of  manufacture  of  card-board  and 
other  materials  for  wadding  undergoes  no  treatment  that  is  calculated 
to  destroy  resistant  bacteria,  and  that  they  are  manufactured  from 
dirty  rags,  old  paper,  wood  pulp,  wool,  etc.,  with  every  opportunity 
for  contamination  our  examinations  were  altogether  negative.^ 
Our  own  examinations,  those  of  the  Director  of  the  Health  Depart- 
ment of  Boston  and  other  cities,  those  of  Wells-  of  Chicago  and  others 
aggregating  675  samples  of  powders  and  wads,  go  to  show  that  the 
bacillus  of  Nicolaier  was  absent  in  every  instance  and  that  the  source 
of  infection  could  not  be  ascribed  to  the  blank  cartridges. 

In  some  experiments  on  animals  we  succeeded  in  communicating 
tetanus  in  69.5  per  cent,  of  the  cases  by  methods  as  follows:  The 
experiments  were  conducted  with  the  .22-caliber  toy-pistol.  An 
artificial  tetanus  earth  was  made  by  mixing  1  quart  of  sterile  earth 
with  one  agar-agar  culture,  after  the  toxin  had  been  destroyed  by 
heating  at  65°  C.  for  five  minutes.  The  animals  were  shot  in  the 
fleshy  part  of  the  thigh. 

(a)  Transmission  by  Infecting  Black  Gunpowder. — One-half  grain 
of  tetanus  earth  was  mixed  with  the  powder  in  each  of  three  blank 
cartridges  with  which  three  white  rats  were  shot  at  a  distance  of  2 
inches.  Two  out  of  the  three  animals  developed  tetanus  and  died 
on  the  fifth  and  sixth  days  respectively. 

(b)  Transmission  by  Infecting  the  Wads  with  Tetanus  Earth. — 
Four  wads  were  infected  on  their  outer  surface  with  a  half  grain  each 
of  the  earth.  Four  rats  were  shot  into  as  stated  above.  Two  ched 
immediately  from  shock  and  the  other  two  succumbed  to  tetanus  five 
days  later. 

1  Mutter  Lecture,  by  the  author,  op.  cit. 

2  Wells,  H.  Gideon,  M.  D.:  An  experimental  study  of  the  origin  of  tetanus  of 
the  epidemic  following  July  4,  1899.  Philadelphia  Medical  Journal,  No.  1377, 
1900. 


138  GUNSHOT    WOUNDS 

(c)  Transmission  by  Placing  the  Earth  on  the  Projectile. — The 

latter  were  infected  b}^  placing  the  earth  in  three  grooves  running 
parallel  with  the  long  axis  of  the  bullet.  Three  rabbits  shot  died 
with  typical  symptoms  of  tetanus  on  the  sixth,  seventh  and  eighth 
days  respectively.  Out  of  three  guinea-pigs  shot  in  the  same  way 
two  died  on  the  sixth  and  seventh  days. 

(d)  Transmission  by  Placing  i  Grain  of  the  Tetanus  Earth  in  the 
Barrel. — Three  white  rats  were  shot  at  2  inches  with  blank  cartridges. 
Two  of  the  animals  died  from  tetanus  on  the  fifth  day. 

(e)  Transmission  by  Shooitng  a  Blank  Cartridge  Through  a 
Piece  of  Gauze  Previously  Contaminated  with  the  Tetanus  Earth,  the 
Gauze  lying  Against  the  Part. — Out  of  five  white  rats  shot  in  this 
manner  three  succumbed  to  tetanus  on  the  fifth  and  sixth  days. 

(f)  Transmission  by  Placing  i  Grain  of  Wet  Tetanus  Earth  on  the 
Skin  of  the  Animal  at  the  Point  Penetrated  by  the  Charge. — Four 
animals  were  thus  shot  with  blank  cartridges,  two  dying  of  typical 
tetanus  on  the  fifth  and  sixth  days. 

(g)  Transmission  by  Infecting  Smokeless  Powder. — The  powder 
was  infected  as  stated  under  (a).  Three  white  rats  were  shot  at  a 
range  of  2  inches.  One  of  them  developed  tetanus  on  the  fifth  daj" 
and  eventually  recovered.     The  other  two  were  negative. 

The  control  animals,  shot  in  the  above  manner  without  the  use  of 
tetanus  earth,  gave  negative  results  T^dthout  exception.  As  stated 
already  the  fatality  from  tetanus  attending  these  experiments  aggre- 
gates 69.5  per  cent.  It  is  fair  to  assume  that  this  percentage  would 
have  been  greater  with  a  pure  culture  of  tetanus.  The  artificial 
tetanus  earth  was  used  to  simulate  the  actual  conditions  under  which 
tetanus  infections  usually  occur. 

We  also  found  that  in  those  cases  where  the  shots  were  delivered 
at  contact  or  thereabouts  exhibiting  burning  or  scorching  from  the 
ignition  of  the  black  powder,  the  development  of  tetanus  was  almost 
invariable,  showing  that  the  coagulation  necrosis  following  burn 
augments  the  tendency  to  the  development  of  tetanus  infection. 

From  the  foregoing  we  felt  justified  in  attributing  the  occurrence 
of  tetanus  in  toy-pistol  wounds  to  the  presence  of  infection  in  the 
contaminated  dust  of  the  street,  which  found  lodgement  on  the  cloth- 
ing, hands,  etc.,  of  those  who  engage  in  the  use  of  toy-pistols  and  py- 
pyrotechnics. 

Treatment. — The  treatment  of  tetanus  is  (a)  local,  (b)  constitu- 
tional and  (c)  specific. 


INFECTION    OF    GUNSHOT   WOUNDS  139 

(a)  Local  Treatment. — A  gunshot  wound  with  a  degree  of  trauma- 
tism as  easily  accessible  as  that  of  a  toy-pistol  injury  should  be 
thoroughly  cleansed  with  a  liberal  use  of  antiseptics.  Every  particle 
of  foreign  matter  should  be  removed  ^vith  soap  and  nail  brush  under 
an  anesthetic.  Loose  tissues  showing  much  laceration  and  contusion 
should  be  cut  away  with  scissors.  Before  the  wound  is  dressed 
antiseptically  injections  of  1  per  cent,  carbolic-acid  solution  should 
be  practised  as  near  the  wound  as  possible  and  they  should  be  re- 
peated dail}^  if  tetanus  supervenes.  Some  Russian  observers  have 
practised  injections  of  emulsion  of  brain  substance  from  small  animals 
in  the  same  way,  after  the  sj-mptoms  of  tetanus  had  set  in  ^^dth 
marked  results.  The  emulsion  is  prepared  bj-  rubbing  together  under 
antiseptic  precautions  10  to  15  gm.  of  brain  substance  from  a  rabbit 
or  guinea  pig  -v^ith  30  c.c.  of  sterile  salt  solution,  and  then  strained 
through  a  sterile  cloth  under  slight  pressure. 

(b)  Constitutional  treatment  includes  supporting  measures  and 
medication.  Among  the  latter  chloroform  by  inhalation  ranks  first  in 
controlling  the  painful  spasms  that  characterize  the  chsease.  Chloral, 
bromides,  canabis  indica  and  opium  have  been  used  for  the  same  reason. 

(c)  The  specific  treatment  is  most  important  as  a  prophylactic 
measure.  Nocard  and  Welch  first  recommended  prophylactic  doses 
of  tetanus  antitoxin  in  veterinary  practice  with  most  profitable  results. 
Doctor  Alexander  Lambert  of  New  York  City  is  a  great  advocate 
of  the  value  of  tetanus  antitoxin  as  a  prophjdactic  measure  against 
tetanus  in  toy-pistol  injuries.  He  cites  the  results  of  1900^  in  New 
York  where  the  Board  of  Health  distributed  antitoxin  to  the  dis- 
pensaries throughout  the  city  for  use  in  toy-pistol  and  other  injuries, 
without  a  single  case  occurring  for  that  year's  fourth  of  July  celebration. 
Early  and  free  use  of  antitoxin  injections,  as  soon  as  possible  after  the 
initial  symptoms  have  declared  themselves,  will  reduce  the  mortality 
as  low  as  40  per  cent.  (Moschowitz).  The  dose  should  be  repeated 
as  often  as  may  be  indicated  by  the  exacerbation  of  the  symptoms. 

When  the  antitoxin  is  used  after  the  onset  of  the  symptoms  it  is 
better  to  inject  it  into  the  spinal  canal.  The  injection  should  be 
preceded  by  drawing  150  to  200  c.c.  of  the  spinal  fluid  to  about  10  to 
15  c.c.  of  the  antitoxin  used.  This  injection  may  be  followed  by  a 
similar  one  with  a  smaller  needle  along  the  large  nerves  leading  to  the 
seat  of  injury.  The  injection  in  the  spinal  canal  may  be  repeated  in 
about  twelve  hours. 

1  New  York  State  Journal  of  Medicine,  No.  4,  1904,  pp.  146-7. 


CHAPTER  V 

The  Treatment  of  Gunshot  Wounds 

The  treatment  of  gunshot  wounds  may  be  divided  into  the  (1) 
Immediate,  (2)  Intermediate,  and  (3)  the  Remote. 

(1)  Immediate. — The  measures  of  treatment  to  be  observed  in 
the  immediate  stage  are  (a)  the  treatment  of  shock,  (b)  arrest  of  hem- 
orrhage, (c)  the  prevention  of  infection. 

(a)  The  treatment  of  shock  has  already  been  discussed  page  117, 
Chapter  III. 

(b)  Arrest  of  Hemorrhage. — The  opportunity  to  arrest  alarming 
hemorrhage  will  depend  upon  the  character  of  the  hemorrhage — 
whether  it  be  external  or  internal.  In  referring  to  the  latter  kind — 
internal  primary  hemorrhage,  page  120,  Chapter  III — we  called  atten- 
tion to  the  apparent  increase  in  the  cases  of  hemorrhage  which  occurs 
in  the  body  cavities  like  the  thorax  and  abdomen  as  a  result  of  the  use 
of  reduced-caliber  bullets.  The  treatment  of  internal  primary  hemor- 
rhage is  attended  with  great  difficulty  because  it  is  usually  accom- 
panied by  pronounced  shock.  Where  life  is  jeopardized,  an  attempt 
should  be  made,  in  localities  which  permit  of  surgical  interference,  to 
cut  down  and  ligate  the  bleeding  vessels  at  the  same  time  that  all 
measures  for  the  relief  of  shock  are  under  way.  External  primary 
hemorrhage,  as  we  have  already  stated,  is  rare.  It  takes  place  from 
vessels  that  are  exposed  or  readily  reached.  But  the  ligation  of  bleed- 
ing vessels  on  the  field  of  battle  and  in  the  emergent  conditions  which 
often  obtain  in  peace  is  most  difficult.  Hemorrhage  of  a  dangerous 
character  rarely  takes  place  in  the  presence  of  trained  attendants  and 
surgeons,  when  all  the  necessary  facilities  for  operation  are  at  hand. 
Until  a  favorable  opportunity  for  interference  has  arrived,  first-aid 
resources  should  be  employed,  and  among  these  may  be  mentioned 
elevation  of  the  injured  part,  extreme  flexion,  digital  compression  and 
antiseptic  tampons.  When  the  foregoing  are  not  sufficient  it  is  neces- 
sary to  employ  constriction,  especially  in  gunshot  wounds  of  the  ex- 
tremities. The  dangers  of  such  a  method  in  the  hands  of  laymen  are 
very  much  minimized  if  the  precaution  is  taken  of  rendering  the 
limb  practically  bloodless  by  gravitation  before  constriction  is  made. 
Constriction  may  be  accomplished  with  an  elastic  bandage,  a  Spanish 

140 


TREATMENT  OF  GUNSHOT  WOUNDS  141 

windlass,  a  pair  of  suspenders,  or  large  handkerchief.  The  hospital 
corps  pouches  in  the  United  States  Army  are  provided  with  a  strap 
of  webbing  holding  a  hard  pad  with  a  buckle  attachment,  to  stay 
hemorrhage  by  constriction,  while  the  orderly  pouches  which  form 
part  of  the  equipment  for  use  of  medical  officers  contain  an  elastic 
bandage  2  yards  long  and  2  inches  wide.  The  constriction  should  be 
made  rapidly,  after  the  limb  has  been  elevated,  with  sufficient  firm- 
ness to  control  the  flow  of  blood  in  the  arteries  and  veins  at  the  point 
of  constriction.  When  pressure  has  been  effectually  applied  as  de- 
scribed it  should  not  be  maintained  longer  than  3  or  4  hours,  to 
avoid  danger  from  gangrene  or  paralysis.  Such  cases  should  remain 
under  the  watchful  care  of  surgeons  who  are  in  possession  of  necessary 
hemostatic  agents  and  equipment  for  ligation. 

(c)  Prevention  of  Infection. — The  prophylaxis  of  infection  in 
military  practice  has  received  a  great  deal  of  attention  in  recent  years. 
The  relief  corps  and  the  rank  and  file  of  all  armies  are  drilled  in  time 
of  peace  in  the  methods  of  rendering  first  aid  to  the  wounded,  a  great 
deal  of  which  is  devoted  to  the  manner  of  preventing  the  introduc- 
tion of  sepsis  into  open  wounds.  Men  under  instruction  are  cautioned 
not  to  touch  the  wound  with  their  fingers  or  to  allow  anything  to  come 
into  contact  with  it  except  a  clean  dressing.  Every  soldier  in  the  U.  S. 
Army  carries  attached  to  his  cartridge  belt  a  first-aid  package  enclosed 
in  a  hermetically  sealed  metal  case.  The  contents  are  made  up  of 
two  bundles  of  absorbent  sublimated  (1  to  1000)  gauze  4  by  84  inches 
long,  two  compresses  of  absorbent  sublimated  (1  to  1000)  gauze,  each 
composed  of  1/2  square  yard  so  folded  as  to  make  a  compress  3  1/2  by 
7  inches,  two  large  safety  pins  wrapped  in  wax  paper.  The  two  com- 
presses and  the  safety  pins  are  wrapped  together  in  tough  paper  in 
which  are  enclosed  printed  directions  for  use  of  the  dressing.  All  the 
contents  are  sterilized  in  a  metallic  case  4  1/2  by  2  1/2  by  1  1/4  inches. 
The  words  ''First-aid  Packet,  U.  S.  Army,"  are  stamped  on  the  metal 
case.  Aside  from  the  value  of  having  these  first-aid  packets  ready  at 
all  times  on  the  line,  the  medical  transportation  is  spared  a  great  deal 
from  the  burden  of  carrying  sufficient  dressing  material  to  meet  all  the 
emergencies  likely  to  arise  at  the  front,  and  much  labor  is  saved  at  the 
dressing  station  when  the  slight  wounds  have  been  properly  dressed  on 
the  line. 

The  first  field  dressing  as  described  had  one  fault,  which  was  un- 
avoidable until  very  recently.  Many  observers,  including  the  late 
Nicholas  Senn,  of  Chicago,  had  sought  to  find  a  dressing  that  should, 


142  GUNSHOT   WOUNDS 

first,  be  clean,  and  which  should,  next,  sterilize  the  skin  about  the 
wound.  Dr.  Senn  employed  a  field  dressing  which  included  in  its 
contents  a  teaspoonful  of  a  powder  composed  of  four  parts  of  boracic 
acid  and  one  part  of  salicylic  acid.  Recently  tincture  of  iodine  has 
come  forth  as  an  ideal  skin  antiseptic  in  surger5^  Colonel  Antelo,  of 
the  Argentine  Army,  advocates  its  use  very  ably  in  an  article  in  the 
Military  Surgeon,  for  December,  1910,  and  it  was  used  by  some  of 
the  Russian  surgeons  very  successfully  in  the  Manchurian  campaign. 
Grossich^  was  probably  the  first  to  formulate  its  use  in  general  surgery. 
He  recommends  the  painting  of  the  field  of  operation  with  tincture  of 
iodine  to  a  clean  skin  just  as  the  patient  is  going  under  the  anesthetic; 
a  second  coat  is  applied  before  the  incision,  and  a  third  coat  is  added 
whent  the  last  suture  has  been  applied.  Major  Woodbury,  of  the  U.  S. 
Arm}',-  has  advocated  its  use  for  some  time  for  sterilizing  the  field  of 
operation,  the  hands  of  the  surgeon,  the  instruments  and  the  ligatures. 
Other  observers  have  used  it  in  emergency  surgery  with  the  greatest 
benefit  by  applying  a  coat  to  the  wound  and  the  skin  surrounding  it 
without  previous  preparation,  with  the  best  of  results.  Hammer  toes 
and  ingrowing  toe  nails  are  operated  upon  in  chspensaries  and  cliuics 
with  no  previous  preparation.  Dr.  John  S.  Neate,^  microscopist 
in  the  Surgeon-General's  Office,  while  working  in  the  laboratories  of 
the  Army  Medical  School,  has  recently  found  that  Lugol's  solution 
may  be  effectually  used  in  place  of  tincture  of  iodine.  He  has  pre- 
pared a  dressing  which  can  be  carried  in  a  sealed  glass  tube.  It  is 
made  of  absorbent  gauze  first  saturated  with  a  strong  solution  of 
potassium  iodide,  and  the  gauze  is  subsequently  impregnated  with 
vapors  of  iodine  crystals.  When  wet  with  water  or  blood  the 
Lugol  mixture  furnishes  all  the  antiseptic  benefits  of  the  tincture. 

Fischer*  states  that  the  surgeons  in  the  Manchurian  campaign 
employed  tincture  of  iodine  to  disinfect  their  hands  and  the  field  about 
the  seat  of  injury.  In  the  late  Italo-Turkish  War  in  North  Africa 
Captain  de  Sarlo^  states  that  tincture  of  iodine  was  very  efficacious  in 
preventing  all  infections  and  especially  the  virulent  infections  like 
tetanus  and  erysipelas. 

1  Centralb.  f.  chir.,  No.  44,  Oct.  31,  1908. 

2  New  York  Medical  Record,  Feb.  11,  1911. 

^  For  work  of  Dr.  Neate  on  Iodine  as  a  Skin  Antiseptic  see  paper  bj^  Dr.  J. 
Wesley  Bovee,  Proceedings  36th  Annual  Meeting  American  Gynecological  Society. 

*  Archives  de  Medecine  et  de  Pharmacie  Mil.,  No.  48,  1906,  by  G.  Fischer. 

^  Notes  on  the  Wounded  at  Derna,  by  Captain  Eugenio  de  Sarlo,  Le  Caducee, 
Nov.  16,  1912.— Ed.  Laval. 


TREATMENT  OF  GUNSHOT  WOUNDS  143 

Iodine  has  recently  been  adopted  for  field  use  in  our  army  as  follows : 
Iodine  is  put  up  in  hermetically  sealed  glass  tubes,  each  tube  containing 
1  gram  of  iodine  and  1.5  grams  of  potassium  iocUde.  Ten  of  these 
tubes  are  put  up  in  a  cardboard  carton.  Each  hospital  corps  man 
carries  one  carton  in  his  pouch,  also  a  4-ounce  bottle. 

By  putting  the  contents  of  two  tubes  in  the  bottle  and  filling  the 
latter  to  its  shoulder  with,  water  or  alcohol  one  is  enabled  to  make  a 
2-per  cent,  solution,  which  is  the  strength  recommended  for  first-aid 
use.  The  sealed  tubes  enter  in  the  equipment  of  the  field  hospitals, 
ambulance  companies  and  reserve  mecUcal  supply  depots.  This 
method  of  carrying  the  iodine  has  the  double  advantage  of  a  prepara- 
tion ready  for  use  as  a  watery  solution  or  a  tincture.  Alcohol  could 
not  be  carried  in  quantities  by  hospital  corps  men  on  the  field,  hence 
the  advisabihtj'  of  having  a  mixture  easily  soluble  in  water  and  which 
can  be  emploj^ed  with  alcohol  when  this  is  available. 

The  greatest  advantage  of  such  a  simple  method  of  sterihzing  the 
skin  about  the  wound  over  the  one  that  prevails  in  fixed  hospitals,  of 
scrubbing  and  washing  with  antiseptic  solutions,  lies  in  the  fact  that 
water  in  bulk  of  suitable  quality  is  seldom  found  in  active  campaign. 

The  iodine  tincture  or  solution  is  painted  over  the  wound  and 
adjacent  skin,  being  careful  not  to  allow  the  preparation  to  collect  in 
recesses  of  the  wound  when  they  are  present.  The  iodine  when  allowed 
to  collect  in  pockets  is  very  irritating  and  its  presence  is  a  detriment. 
The  wound  is  next  dressed  with  the  first-aid  dressing  previously 
described.  In  large  lacerated  wounds  the  contents  of  several  of  the 
first-aid  packets  may  be  used  or  in  the  case  of  shell  wounds,  we  carry 
in  the  United  States  Army  a  field  dressing  as  follows:  (1)  a  compress 
composed  of  1  square  yard  of  absorbent  subhmated  (1-1000)  gauze 
folded  to  make  a  pad  6  by  9  inches;  (2)  one  bandage  3  inches  wide  by 
5  yards  long  of  closely  woven  absorbent  gauze  (1-1000)  rolled  and 
wrapped  in  parchment  or  waxed  paper,  and  (3)  two  No.  3  safety  pins 
wrapped  in  waxed  paper.  The  whole  dressing  is  wrapped  in  tough  paper 
with  proper  directions  for  use  printed  thereon.  Short  bandages  are 
sewed  to  the  compresses  for  the  purpose  of  temporarily  fixing  the  latter 
on  the  wound,  after  which  they  are  firmly  bound  to  the  parts  by  the 
roller  bandage. 

The  field  dressings  of  all  armies  are  about  the  same,  since  they 
are  intended  to  subserve  the  same  purpose.  The  dressings  are  absor- 
bent and  protective  in  design.  An  abundance  of  absorbent  dressing, 
is  of  special  value  to  the  military   surgeon  in  field  practice.     By 


144  GUNSHOT   WOUNDS 

covering  the  wound  completely  with  plenty  of  absorbent  dressing, 
and  in  cases  of  deep  lacerated  wounds  if  the  dressing  is  loosely  packed 
in  the  wound,  drainage  will  be  maintained  until  a  favorable  oppor- 
tunitj^  for  redressing.  In  the  case  of  large  wounds  when  the  time  for 
redressing  is  indefinite,  as  often  occurs  in  the  emergent  conditions  of 
active  campaign,  cotton  batting  should  be  used  over  the  absorbent 
dressing  to  protect  the  wound  from  outside  contamination.  With 
such  a  dressing  it  is  possible  to  carry  the  wounded  over  several  days 
until  a  field  hospital  has  been  reached,  when  all  facilities  are  at  hand 
for  antiseptic  and  operative  work. 

Immobilization. — Fixation  of  wounded  parts  plays  a  great  role  in 
gunshot  wounds  as  a  prophylactic  against  infection.  When  enforced 
transport  is  necessary,  as  so  often  happens  in  military  practice,  it 
adds  much  to  the  comfort  of  the  patient  in  keeping  down  pain;  it 
tends  to  prevent  the  recurrence  of  hemorrhage,  and  it  favors  early 
healing. 

When  soft  parts  alone  are  wounded  we  immobilize  by  means  of 
slings,  a  firmly  fitting  bandage,  or  splints  to  keep  the  wounded  part 
at  rest.  In  the  case  of  wound  of  the  chest  or  abdomen  we  apply  a 
firm  bandage  about  the  body  to  check  respiratory  movements. 

Immobilization  is  also  of  special  value  in  gunshot  fractures. 
As  soon  as  the  first  dressing  has  been  applied  fixation  of  the  fragments 
is  accomplished  by  woven  wire  splints,  which  are  carried  in  the  pouches 
of  the  relief  corps  men,  also  by  extemporized  methods  such  as  immobiliz- 
ing the  fractured  arm  or  forearm  to  the  chest  by  bandaging  the  member 
to  the  body.  In  fracture  of  the  lower  extremity  in  military  practice, 
in  the  absence  of  anything  better,  we  improvise  splints  from  folded 
blankets,  gun  scabbards,  bayonets  or  rifles. 

Immobilization  in  all  bone  lesions,  whether  there  is  distinct 
solution  of  continuity  or  not,  should  invariably  be  practised,  and 
especially  so  after  lesion  from  the  armored  bullets.  These  hard 
projectiles,  when  hitting  the  joint  ends  of  the  long  bones,  and  also 
the  diaphyses,  in  the  mid  ranges,  have  a  tendency  to  perforate 
or  gutter  a  bone  without  causing  complete  fracture.  Transport  and 
handling  of  a  limb  so  injured  without  immobilization  endangers 
the  occurrence  of  fracture  and  other  traumatisms,  which  augment 
the  danger  to  infection.  Such  an  injury  should  be  treated  by  per- 
manent fixation  at  once  and  it  should  not  be  handled  unnecessarily, 
Many  of  these  lesions,  especially  in  the  diaphyses,  consist  of  perfora- 
tion with  subperiosteal  fissures  extending  in  the  long  axis  of  the  bone 


TREATMENT  OF  GUNSHOT  WOUNDS  145 

and  when  the  overlying  support  gives  way  from  jolting,  jarring  or 
undue  handling,  fracture  takes  place.  This  fact  was  referred  to 
in  our  report  to  the  Surgeon-General  in  1893,  when  we  tested  a  German 
silver  30-caliber  jacketed  bullet  in  cadavers  under  the  orders  of  the 
War  Department.^ 

In  the  living  the  case  of  Major  T.  J.  W.,  10th  U.  S.  Cavalry, 
wounded  at  Santiago,  is  most  applicable.  He  was  wounded  at  6  p.  m., 
July  1,  while  in  the  standing  posture  looking  through  his  field  glasses- 
He  felt  a  sharp  blow  on  the  left  thigh  which  whirled  him  around. 
In  endeavoring  to  pick  up  a  pipe-stem  which  had  fallen  from  his  hand 
he  fell  to  the  ground  and  called  for  assistance  to  place  him  over  the 
crest  of  the  hill  out  of  the  line  of  fire.  Wound  of  entrance  by  a 
Mauser  bullet  was  found  located  at  lower  angle  Scarpa's  triangle 
and  the  wound  of  exit  just  below  the  rim  of  the  pelvis  on  a  line  drawn 
from  the  center  of  the  rim  to  the  greater  trochanter.  The  ball  pierced 
the  trousers  pocket  and  a  pocketbook  therein  and  emerged  from  the 
skin,  lodging  in  the  trousers  near  the  point  of  exit,  where  it  was 
recovered.  The  passage  of  the  ball  through  the  thigh  was  from 
within,  and  below  upward.  A  surgeon  dressed  the  wound  temporarily 
at  once  and  applied  splints  from  above  hip  at  loin  to  ankle  outside, 
and  an  inside  splint  from  crotch  to  ankle.  Fracture  was  diagnosed. 
After  about  one  hour  he  was  carried  on  an  improvised  stretcher  to  a 
dressing  station  about  3/4  mile  to  the  rear.  No  redressing  was 
done  here  and  splint  was  not  disturbed.  The  same  night  he  was 
transported  on  a  stretcher  4  miles  to  the  field  hospital  where  about 
1  A.  M. ,  July  2,  the  wound  was  dressed  and  leg  again  examined  and 
fracture  diagnosed  by  a  second  surgeon.  The  splints  were  reapplied 
and  left  on  for  two  days  more.  A  third  examination  was  made  when 
thigh  was  pronounced  not  fractured  and  the  splints  were  removed. 
July  10  splints  were  reapplied  and  the  patient  was  transported  7 
miles  over  a  rough  road  to  the  Reserve  Divisional  Hospital  at  Siboney. 
We  were  in  command  of  the  Division  Hospital  at  Siboney  and  in  charge 
of  the  evacuation  of  wounded.  July  11,  the  day  after  arriving  from 
the  front,  we  had  Major  W.  and  a  great  many  wounded  loaded  on  the 
hospital  ship  Relief.  His  thigh  was  then  in  splints,  the  same  as  those 
applied  on  the  day  before  in  the  field.  The  celebrated  Surgeon 
Nicholas  Senn  of  Chicago,  then  Lt.-Col.  of  Volunteers  and  consulting 
surgeon  with  the  army  in  the  field,  examined  this  officer  while  he  was 
in  the  Division  Hospital  at  the  front  and  he  gave  it  as  his  opinion 

^  See  Annual  Report,  Surgeon  General,  U.  S.  Army,  1893. 


146  GUNSHOT    WOUNDS 

that  there  was  no  fracture.  Two  radiographic  plates  were  made  on 
the  hospital  ship  Relief  by  Doctor  Wm.  M.  Gray.  Fig.  86  is  made 
from  the  skiagram  of  one  of  the  plates.  It  shows  no  fractm'e,  but  part 
of  the  greater  trochanter  gives  evidence  of  guttering  in  the  line  of 
flight  of  the  projectile  from  below  upward. 


Fig.  86. — Case  of  Major  T.  J.  W.  10th  Cavalry,  showing  t;rooving  of  the  trochanter  major.     Army 

Medical  School  collection. 

July  26  patient  was  transferred  from  the  hospital  ship  Relief  to 
the  New  York  Hospital.  On  admission  the  limb  had  no  sphnts. 
A  fluoroscopic  examination  showed  an  obhque  fracture  through  base 
of  neck  and  part  of  greater  trochanter  with  abundant  callous  and  much 
displacement.  The  limb  was  found  to  be  flexed  and  shortened  2  1/2 
inches.  Wound  exit  was  closed,  wound  entrance  was  suppurating 
slightly.     No  crepitus,  no  false  motion,  considerable  tenderness  and 


TREATMENT  OF  GUNSHOT  WOUNDS  147 

swelling  about  knee-joint.  September  15  discharged  from  New  York 
Hospital,  with  good  motion  of  limb,  shortening  1/2  inch.  Took  to 
crutches  September  6,  could  bear  some  weight  on  injured  leg.  Major 
W.  made  a  good  recovery  later  and  became  a  General  Officer.  The 
complete  fracture  took  place  after  Doctor  Gray's  radiographic  plate 
was  taken  on  the  Relief. 

The  injur}'-  to  the  bone  was  made  by  a  Mauser  bullet  which  had 
lost  some  of  its  remaining  velocity  because  it  was  lodged  in  the  clothing 
as  stated.  It  perforated  the  cancellous  tissue  of  the  greater  trochanter 
which,  like  the  epiphyseal  ends  of  bones,  exhibits  perforation  rather 
than  fracture,  especially  with  lower  velocities.  The  mistake  made 
was  in  taking  off  the  splints  before  his  admission  to  the  New  York 
Hospital.  We  know  so  much  more  about  the  effects  of  reduced- 
caliber  bullets  now  that  such  a  mistake  is  not  likely  to  occur  hereafter. 

The  measures  calculated  to  prevent  infection  in  the  early  treat- 
ment of  gunshot  wounds  may  be  summed  up  as  follows: 

1.  The  first  dressing  should  be  sterile,  applied  over  a  surface  that 
has  been  painted  with  iodine. 

2.  No  attempt  should  be  made  to  disinfect  the  wound  proper  on 
the  battle  field. 

3.  Probing  for  bullets  or  the  use  of  even  a  sterile  finger  in  a  wound 
is  absolutely  prohibited. 

4.  The  severely  wounded,  and  gunshot  fractures  should  not  be 
transported  unnecessarily. 

5.  Immobilization  when  indicated  should  be  practised  at  once, 
and  in  bone  lesion  with  or  without  fracture  it  should  be  maintained 
until  firm  bony  union  has  occurred. 

(2)  Intermediate  Treatment. — The  intermechate  treatment  is  done 
in  a  field,  base  or  well  equipped  hospital  in  military  or  civil  practice. 
It  should  be  preceded  by  a  thorough  examination  and  the  measures 
of  relief  to  be  instituted  will  be  guided  to  a  great  extent  by  the  X-ray 
evidence  as  well  as  the  local  and  general  symptoms.  In  accordance 
with  the  findings  the  measures  of  treatment  will  include  redressing 
of  wounds,  the  proper  use  of  disinfection  and  drainage,  the  treatment 
of  existing  infection,  removal  of  foreign  bodies,  and  loose  fragments  of 
bone;  excisions,  amputations,  laparotomies,  administration  of  food 
and  stimulants,  ligation  for  aneurysm,  hemorrhage,  and  the  treatment 
of  secondary  hemorrhage. 

Simple  gunshot  wounds  by  the  armored  reduced-caliber  bullets 
require  no  additional  treatment  after  the  application  of  the  first  field 


148  GUNSHOT   WOUNDS 

dressing.  At  least  that  was  our  experience  at  the  Reserve  Division 
Hospital  at  Siboney  after  the  battle  of  Santiago.  The  wounded 
commenced  to  enter  the  hospital  late  on  the  day  of  battle  and  con- 
tinued to  arrive  for  several  days  thereafter.  The  simple  wounds,  in 
which  the  bullets  had  traversed  unimportant  soft  parts,  were  covered 
by  dry  blood  clots  and  they  were  healing  under  the  first  field  dressing. 
In  the  majority  of  the  cases  the  latter  was  renewed,  although  there 
seemed  to  be  no  indication  for  this  expenditure  of  valuable  time  and 
extra  dressings,  except  in  those  cases  where  the  dressings  had  become 
disarranged. 

No  attempt  should  be  made  to  invade  the  bullet's  track  for  the 
purpose  of  sterilizing  the  wound.  As  we  have  already  stated  in  the 
chapter  on  Infection  of  Gunshot  Wounds,  all  the  wounds  of  this  class 
are  of  necessity  infected.  During  the  earlier  use  of  antiseptics, 
surgeons  essayed  the  use  of  antiseptics  in  gunshot  wounds  as  they 
did  for  unclean  wounds  generally,  with  unfortunate  results. 

To  determine  the  effects  of  antiseptic  measures  upon  the  track 
made  by  a  bullet,  Miiller  and  Koller  made  interesting  experiments 
upon  rabbits.  They  tried  varying  methods  of  treatment  in  wounds 
inflicted  by  projectiles  that  were  primarily  infected  as  follows: 

1.  Controls  for  which  nothing  was  done. 

2.  Those  treated  with  glass  drain. 

3.  Those  treated  with  an  iodoform-gauze  drain. 

4.  Those  treated  with  5  per  cent,  solution  carbolic  acid. 

5.  Those  treated  by  swabbing  with  a  cotton  mop  soaked  in  tincture 
of  iodine. 

6.  Those  treated  by  cauterizing  the  track  from  the  wound  of  en- 
trance to  the  wound  of  exit. 

All  the  wounds  were  dressed  with  a  clean  sterile  dressing.  The 
results  showed  that  the  wounds  treated  with  simple  dressings  did 
best  of  all,  and  that  those  treated  by  the  radical  measures  mentioned, 
such  as  swabbing  with  tincture  of  iodine  and  the  application  of  the 
cautery,  gave  evidence  of  active  suppuration  in  every  instance.  Von 
Bergmann's  first  efforts  to  treat  gunshot  wounds  in  war  radically 
ended  disastrously.  In  the  early  part  of  the  Russo-Turkish  war  he 
disinfected,  drained,  and  dressed  antiseptically,  but  his  results  were 
disappointing  in  the  extreme. 

The  vain  efforts  of  these  investigators  are  easily  explained  by  ex- 
perimental evidence.  In  some  tests  already  referred  to  we  found  that 
carbon  particle,  when  rubbed  on  the  skin  of  rabbits  which  were  next 


TREATMENT  OF  GUNSHOT  WOUNDS  149 

shot  with  weapons  of  various  calibers,  were  driven  as  far  as  17  mm.  into 
the  tissues  surrounding  the  channel  of  gunshot  wounds,  and  that  the 
distance  to  which  tissues  may  be  so  invaded  depends  upon  the 
velocity  and  sectional  area  of  the  bullet.  From  the  foregoing  we 
have  to  assume  that  infection  of  any  kind  which  finds  lodgment  on  the 
ball,  the  clothing  or  skin,  would  be  dispersed  similarly  and  that  all 
attempts  to  reach  such  infection  by  the  ordinary  means  of  cleansing 
must  end  in  failure.  Speaking  generally,  we  should  be  content  to 
treat  a  gunshot  wound  by  the  application  of  tincture  of  iodine, 
and  the  first  field  dressing  at  the  earliest  time  practicable  after  the 
receipt  of  the  injury.  In  such  cases  one  has  to  rely  on  the  local  and 
general  resistance  of  the  individual  to  ward  off  the  development  of 
infection.  That  such  a  course  is  wise  and  proper  is  shown  by  the 
prompt  healing  in  the  large  majority  of  simple  gunshot  wounds  by 
the  projectiles  of  ordinary  hand  weapons. 

Examination  of  Gunshot  Wounds. — The  old-time  method  of  ex- 
amining gunshot  wounds  with  bullet  detectors  and  probes  of  various 
kinds  has  been  made  obsolete,  in  military  surgery  at  least,  by  the  use 
of  the  steel-clad  bullets  that  do  not  lodge  as  often  as  the  old  leaden 
projectiles.  Again  we  depend  upon  the  use  of  the -X-ray  to  locate 
lodged  missiles  of  all  kinds  and  to  interpret  bone  lesions,  which  often 
determines  the  necessity  for  or  against  operation.  The  rule  of  cutting 
down  in  all  cases  of  gunshot  injury  for  diagnostic  purposes  is  unneces- 
sary. The  position  of  the  fragments  can  be  ascertained  by  a  study  of 
a  Rontgen  ray  plate  for  all  practical  purposes.  As  long  as  the 
wound  remains  aseptic  the  fragments  of  bone  will  retain  their  vitality 
and  they  will  serve  a  useful  purpose  in  the  healing  process.  There  are 
only  two  indications  for  cutting  down  upon  a  gunshot  wound.  The 
first  is  in  the  case  of  a  lodged  missile  after  its  location  by  the  X-ray, 
and  the  second  is  in  case  of  gunshot  fractures  when  infection  has 
appeared  or  is  threatened  by  the  pressure  of  many  loose  fragments. 

Removal  of  lodged  missiles  more  properly  belongs  to  the  Remote 
Treatment  and  it  will  be  dealt  with  under  that  head. 

When  a  gunshot  fracture  of  the  upper  or  lower  extremity  becomes 
infected  the  surgeon  should  cut  down  boldly  and  practise  debridement 
with  all  the  significance  that  the  meaning  of  the  word  bore  for  the  older 
surgeons  who  employed  it  in  the  days  when  sepsis  was  the  rule  in  all 
wounds.  Thorough  tubular  drainage,  removal  of  free  and  infected 
fragments  of  bone  and  any  lodged  material,  and  the  liberal  use  of  dis- 
infectants should  be  practised.     Frequent  irrigation  with  bichloride 


150  GUNSHOT   WOUNDS 

of  mercury  1-4000  or  carbolic  acid  1-40  should  he  resorted  to,  or,  if 
intermittent  irrigation  fails,  continued  irrigation  with  a  saturated  solu- 
tion of  acetate  of  lead  as  recommended  by  the  late  Nicholas  Senn^ 
should  be  employed.  Infection  in  gunshot  fracture  is  often  difficult 
to  treat  successfully  because  infected  areas  are  inaccessible.  When- 
ever thorough  drainage  is  obtained  the  septic  condition  disappears  in 
a  short  time  under  irrigation  as  mentioned.  As  soon  as  union  has 
commenced  to  take  place  extension  and  counter-extension  or  the 
fracture  box  should  be  replaced  by  a  properly  adjusted  plaster  of 
Paris  cast,  and  as  early  as  possible  the  patient  should  walk  or  be 
rolled  into  the  open  air. 

The  author  has  purposely  withheld  comment  on  the  different 
bullet  detectors  and  extractors  because  their  use  is  not  contem- 
plated in  the  modern  treatment  of  gunshot  wounds.  Nelaton  probes 
seldom  have  application  as  detectors  because  the  projectiles  now  are 
made  of  hard  metals  which  leave  no  mark  on  the  porcelain  tip.  The 
telephone  probe  is  uncertain  in  its  mechanism  and  often  misleadng. 
Bullet  extractors  are  superfluous  and  their  place  is  easily  filled  by  the 
many  different  forceps  in  the  armamentarium  of  the  surgeon.  Ex- 
traction of  a  bullet  through  the  track  which  it  has  made  should  be 
avoided  in  all  cases.  To  tamper  with  these  already  contused  and  lac- 
erated tissues  only  spreads  existing  infection  and  it  adds  to  the  danger 
of  systemic  infection  by  breaking  up  the  lymph  barriers  that  nature  is 
establishing  to  prevent  it.  If  it  is  necessary  to  remove  the  projectile, 
in  the  intermediate  stage,  after  it  has  been  definitely  located,  it  is 
better  to  cut  down  de  novo  under  strict  antiseptic  precautions  and  thus 
remove  the  projectile  from  its  place  of  lodgment.  Our  experience 
following  the  battle  of  Santiago  demonstrated  that  the  patients  them- 
selves were  restless  until  the  lodged  missiles  were  removed.  In  this 
battle  10  per  cent,  of  the  rifie-bullet  wounds  had  lodged  balls,  a  fact 
that  was  explained  largely  by  the  uneven  topography  of  the  terrain,  and 
an  abundance  of  underbrush  between  the  opposing  armies.  The  maj  or- 
ity  of  the  projectiles  removed  gave  evidence  of  indentation  or  other 
deformation  from  ricochet.  We  were  short  of  dressings  in  the  extreme, 
and  the  orders  were  to  refrain  from  removing  lodged  balls  except  in 
cases  of  actual  necessitj^,  an  order  which  we  regret  to  state  was  not 
always  complied  with  by  the  operating  staff. 

^  The  Modern  Treatment  of  Gunshot  Wounds  in  MiHtary  Practice,  The  ]MiH- 
tary  Surgeon,  1898,  by  Nicholas  Senn,  Lt.  Col.  U.  S.  Volunteers. 


TREATMENT  OF  GUNSHOT  WOUNDS  151 

Administration  of  Food  and  Stimulants. — The  value  of  proper  food 
and  stimulants  to  the  wounded  can  only  be  appreciated  by  those  who 
have  witnessed  their  effects  on  men  who  have  been  wounded  in  battle 
which,  as  frequently  occurs,  has  been  preceded  by  fatiguing  forced 
marches,  loss  of  sleep,  and  lack  of  food.  As  often  happens  the 
wounded  have  lost  blood,  and  they  have  suffered  pain  and  many 
discomforts  in  transport.  Under  these  trying  conditions  men  are  in 
a  low  state  of  nutrition  and  vital  power.  Their  resistance  to  microbic 
influences  is  much  impaired  and  they  are  specially  downcast  in  spirits. 
At  such  a  time  nothing  is  more  indicated  than  food  of  a  nourishing 
and  stimulating  kind.  At  Siboney  after  the  battle  of  Santiago,  we 
had  a  staff  of  helpers  whose  office  was  to  supply  the  injured  with 
beef  tea,  hot  gruel,  chocolate,  tea  and  coffee.  We  had  captured  a 
wine  cellar  on  landing,  which  served  the  wounded  with  good  burgundy, 
claret  and  sherry  when  required. 

In  our  Army,  field,  evacuation  and  base  hospitals  are  provided  with 
hospital  stores  for  the  sick  in  the  way  of  beef-tea,  brandy,  chocolate, 
condensed  milk,  malted  milk,  rolled  oats,  soups,  green  and  black  tea, 
and  whiskey.  The  dressing  stations  are  supplied  similarly.  The 
effect  of  these  necessary  and  kindly  attentions  to  the  wounded  is 
magical.  They  become  conscious  of  the  presence  of  substantial  help 
about  them.  Their  hopes  are  raised  and  their  despondency  is  replaced 
by  good  cheer. 

Inattention  to  the  details  of  early  feeding  after  great  battles  is  one 
of  the  fruitful  causes  of  death.  Surgeons  in  the  field  should  make 
special  efforts  to  provide  themselves  with  the  articles  mentioned 
when  the  battle  is  impending;  the  good  results  thereafter  will  be  in 
keeping  udth  the  preparations  made  in  advance.  The  allowance  on 
the  supply  table  should  be  no  guide,  it  should  be  multiplied  many 
times  if  opportunity  offers. 

Hemorrhage. — As  stated  already,  severe  external  primary  hemor- 
rhage of  the  kind  that  requires  ligation  of  vessels,  from  present-day 
rifle  bullets,  is  uncommon.  It  was  not  common  mth  the  old  arma- 
ment and  it  is  thought  to  be  less  so  with  the  new.  Of  the  1400  wounded 
at  the  battle  of  Santiago  no  death  from  external  primary  hemor- 
rhage was  recorded  and  no  vessel  was  tied  on  the  field  to  arrest  this 
kind  of  hemorrhage.  The  experience  of  the  English  surgeons  in  the 
Boer  War  and  the  reports  of  Follenfant  on  the  Russian  side  in 
Manchuria  confirm  the  rarity  of  avoidable  primary  hemorrhage  on 
the  field. 


152  GUNSHOT   WOUNDS 

At  the  same  time  that  this  kind  of  hemorrhage  is  specially  rare 
with  out  present  armament,  as  we  will  explain  when  treating  of 
aneurysm  and  injury  to  blood-vessels,  injury  to  the  latter  is  more 
often  seen.  The  vessels  are  often  grazed,  their  coats  are  partially 
destroyed  and  the  remaining  support  gives  way  causing  a  hemorrhage 
later.  These  cases  occur  in  the  intermediate  stage  of  the  manage- 
ment of  gunshot  wounds,  and  they  are  to  be  dealt  with  at  the  field  or 
base  hospitals.  Here  also  we  are  apt  to  have  cases  of  recurring 
hemorrhage  in  wounds  where  the  temporary  obstruction,  like  inter- 
vening layers  of  tissue  or  clot,  give  way  with  the  recurrence  of  bleeding. 
Most  generally  these  cases  have  to  be  treated  by  ligation,  an  operation 
which  can  be  more  properly  performed  at  a  field  hospital  where  the 
necessary  facilities  and  trained  assistants  are  at  hand. 

Secondary  Hemorrhage. — Thanks  to  antisepsis  secondary  hemor- 
rhage is  now  comparatively  rare  in  war  hospitals.  As  this  form  of  hem- 
orrhage is  mostly  due  to  the  invasion  of  septic  organism  into  wounds, 
it  was  common  in  preantiseptic  days  and  it  caused  great  mortality. 
With  our  present  methods  of  dressing  wounds,  we  prevent  sepsis,  and  it 
may  be  said  that  secondary  hemorrhage  from  septic  conditions  is  now 
as  rare  as  it  was  common  before.  However,  the  traumatism  incident 
to  the  mechanical  effects  of  a  bullet  traversing  soft  and  bony  tissues 
will  leave  conditions  at  times  that  cause  secondary  hemorrhage  inde- 
pendently of  sepsis:  (a)  a  specula  of  bone  adjacent  to  a  vessel,  in 
transport  may  by  its  pointed,  irregular  or  jagged  edge,  lacerate  or  cut 
an  artery  and  thereby  set  up  hemorrhage;  (b)  a  vessel's  coats  may 
not  be  entirely  cut  away,  and  here  again  the  hurtful  effects  of  enforced 
transport  are  seen.  A  vessel  whose  coats  are  cut  away,  excepting 
the  intima,  should  be  kept  as  quiet  as  possible,  but  the  emergent 
conditions  in  war  often  compel  transport,  and  the  jolting  and  jarring 
in  all  kinds  of  vehicles,  over  rough  roads,  tend  to  cause  hemorrhage  by 
rupture  of  the  remaining  barrier. 

The  treatment  of  secondary  hemorrhage  is  (a)  by  ligation  of  the 
vessel  in  the  wound,  (b)  by  ligation  of  the  main  artery  of  the  limb, 
(c)  by  amputation. 

When  secondary  hemorrhage  first  takes  place  a  tourniquet  should 
be  applied  and  an  antiseptic  tampon  should  be  packed  in  the  wound 
under  firm  pressure.  As  soon  as  proper  preparations  have  been  made 
the  surgeon  should  open  up  the  wound  under  antiseptic  precautions 
and  search  for  the  bleeding  vessel  with  a  view  to  its  ligation.  In 
securing  the  vessel  the  surgeon  should  satisfy  himself  that  he   is 


TREATMENT  OF  GUNSHOT  WOUNDS  153 

applying  his  ligature  to  the  healthy  part  of  the  vessel  wall,  because  the 
coats  of  an  arterj^  in  septic  cases  are  apt  to  undergo  slough,  like  the 
rest  of  the  tissues.  The  wound  should  next  be  thoroughly  drained 
and  cleaned  by  irrigation  with  antisej)tic  solutions  like  mercuric 
bichlorid  1-4000,  acid  carbolic  1-40,  etc. 

In  those  cases  in  which  the  bleeding  vessel  cannot  be  found,  or 
where  there  seems  to  be  oozing  from  one  particular  locality  the  actual 
cautery  is  indicated.  The  same  resource  may  be  employed  where  it 
is  difficult  to  find  a  healthy  vessel  to  tie  conveniently.  The  latter 
may  be  seared  with  the  cautery  at  a  point  where  it  appears  healthy, 
provided  it  is  not  too  large.  In  wounds  of  the  extremities  the  prac- 
tice is  to  cut  down  upon  the  main  artery  and  tie  on  the  proximal  side 
of  the  wound.  If  hemorrhage  still  persists  or  if  gangrene  sets  in,  a 
misfortune  not  uncommon  in  the  lower  limb,  amputation  is  next  in 
order.  Proximal  ligations  succeed  better  in  the  upper  extremity,  but 
the  rule  there  also  is  to  amputate,  if  the  hemorrhage  recurs  after 
ligation.  Amputations  are  often  performed  in  military  hospitals 
under  these  circumstances,  because  of  exigencies  in  military  practice 
that  might  be  avoided  in  civil  hospitals  where  the  surgeon  has  entire 
command  of  the  environments.  To  persevere  and  temporize  in  the 
military  service  means  time,  dressings  that  are  often  scarce  and  attend- 
ants whose  services  are  necessary  for  the  alleviation  of  suffering  to  a 
greater  number  of  wounded.  Under  such  circumstances  it  is  the 
safer  course  for  the  sake  of  the  one  whose  limb  is  in  jeopardy  to 
amputate,  and  dress,  rather  than  to  persist  under  difficulties,  with 
no  assurance  of  succeeding  perfectly.  The  harm  that  may  be  done 
to  one  wounded  is  compensated  for  by  the  greater  amount  of  good  that 
comes  to  those  who  might  be  otherwise  neglected. 

Whenever  it  is  possible  to  command  the  movements  of  patients 
it  is  better  to  keep  the  serious  cases,  at  least,  as  quiet  as  possible. 
Those  who  have  lost  blood  and  who  have  sustained  operations  should 
receive  supporting  treatment  of  a  special  kind. 

(3)  Remote  Treatment. — In  the  later  or  chronic  stages  of  gunshot 
wounds  it  often  becomes  necessary  to  operate  for  removal  of  foreign 
bodies  after  their  location  has  been  definitely  ascertained  by  X-ray 
examination.  The  removal  of  necrosed  bone,  once  the  source  of  a 
great  deal  of  protracted  suffering  in  gunshot  wounds,  has  to  be  prac- 
tised occasionally  nowadays,  in  old  wounds,  as  a  result  of  infection 
which  persists  or  recurs  from  time  to  time. 

The  correction  of  deformities  and  restoration  of  loss  of  function 


154  GUNSHOT   WOUNDS 

from  injury  to  certain  anatomical  parts  will  come  in  for  a  certain  part 
of  the  after-treatment,  such  as  plastic  operations  to  correct  deformities 
following  cicatrization  of  extensive  wounds  and  burns,  and  the  restor- 
ation of  function  by  the  operation  for  severed  tendons  and  nerves. 
Of  the  many  disabling  and  remote  consequences  of  gunshot  injuries, 
the  lodgement  of  foreign  bodies  is  probably  the  most  common.  These 
are  to  be  removed  by  surgical  operation  whenever  practicable. 


CHAPTER  VI 

Gunshot  Wounds  of  the  (1)  Head,  (2)  Face  and  (3)  Neck 

1.  Gunshot  Wounds  of  the  Head. — The  ratio  of  gunshot  hijuries 
of  the  head  to  the  total  number  of  casualties  in  battle  has  always 
been  relatively  high,  but  it  has  increased  very  much  with  the 
rapidity  and  accuracy  of  fire  of  modern  arms.  According  to  Long- 
more  the  head  and  face  offer  a  target  area  of  5.89  per  cent,  com- 
pared to  the  target  area  of  the  rest  of  the  body.  If  men  fought 
standing  the  percentage  of  head  wounds  to  the  total  number  of 
casualties  would  correspond  very  closely  to  the  above  ratio.  In 
modern  wars  the  tactician  drills  his  soldiers  to  fight  under  cover 
as  much  as  possible.  As  a  consequence  the  head  is  exposed  to  fire 
longer  and  more  often  than  the  remainder  of  the  body.  Again, 
in  siege  operations  and  fighting  from  entrenched  positions  the  head 
and  upper  part  of  the  body  are  necessarilj''  more  often  and  longer  ex- 
posed so  that  the  ratio  of  head  wounds  is  relatively  higher  among  those 
defending  fortified  positions.  The  Crimean  War  is  cited  by  writers  as 
a  typical  example  of  the  effects  of  fighting  behind  entrenchments,  and 
as  a  result  20  per  cent,  of  all  the  gunshots  treated  were  of  the  head, 
face,  and  neck. 

The  Spanish-American  War,  in  which  siege  operations  figured 
but  httle,  gives  a  fairly  good  idea  of  the  frequency  of  head  wounds  in 
modern  wars.  In  4756  gunshot  injuries  in  all  parts  of  the  body,  the 
head,  face  and  neck  were  injured  in  15.26  per  cent.^  of  the  total. 
Fischer^  gives  20  per  cent,  of  head  wounds  for  all  gunshot  injuries  in 
the  Manchurian  campaign. 

Gunshot  wounds  of  the  head  may  be  divided  into  (a)  those  of  the 
scalp;  (b)  shot  wounds  of  the  skull  without  lesion  of  cranial  contents 
such  as,  contusion,  guttering  and  fracture  of  the  outer  or  inner  table 
alone;  (c)  shot  fracture  of  the  skull  with  attending  brain  injury. 

(a)  Gunshot  Wounds  of  the  Scalp. — ^Contused  or  lacerated  wounds 
of  the  scalp  are  rarely  fatal.  Out  of  7739  scalp  wounds  by  gunshots 
in  our  Civil  War,  Otis  reported  a  mortality  of  2.09  per  cent.  The 
fatalities  are  attributed  to  erysipelas,  meningeal  inflammation,  gan- 

1  Annual  Report  S.  G.,  U.  S.  A.,  1900. 

2  Archives  de  Med.  et  Phar.  Mil.,  No.  48,  1906,  p.a02. 

155 


156  GUNSHOT   WOUNDS 

grene,  tetanus,  pyemia,  etc.  Doubtless  some  of  the  fatal  cases  of 
wounds  of  the  scalp,  as  pointed  out  by  certain  authors,  include  lesion 
of  the  skull  that  is  not  easily  determined.  Thus  Chenu  reports  a 
mortality  of  nearly  10  per  cent,  in  1633  contusions  and  simple  wounds 
of  the  scalp  among  the  French  troops  in  the  Crimea.  The  divergence 
of  the  figures  given  by  the  two  authors  would  indicate  that  a  certain 
percentage  of  the  French  wounded  had  suffered  from  unrecognized 
cranial  injuries. 

From  present-day  military  rifle  bullets,  wound  of  the  scalp  per  se, 
as  a  result  of  superficial  glancing  and  grazing  shots,  should  be  attended 
with  no  mortality.  Writers  from  the  Boer  War  observe  that  grazing 
shots  exhibited  loss  of  substance,  ''the  skin  being  actually  carried 
away  by  the  bullet"  (Makins).  Scalp  wounds  from  shell  fragments  and 
shrapnel  are  irregular  and  lacerated.  The  wound  is  larger  as  a  rule 
than  those  made  by  the  rifle  bullet  and  they  are  more  prone  to  in- 
fection. 

Treatment  of  Shot  Wounds  of  the  Scalp. — No  class  of  wounds 
should  receive  greater  care  in  the  primary  dressing  than  head  wounds. 
The  dirt  of  the  scalp  is  constant,  and  no  scalp  wound  escapes  infection. 
The  surgeon's  aim  from  the  first  should  be  directed  to  minimize  the 
amount  of  infection  present  in  the  wound.  In  active  campaign  and 
during  other  emergent  conditions  the  surgeon  has  in  tincture  of  iodine 
a  great  aid  for  the  subjection  or  prevention  of  sepsis.  The  hair  should 
be  either  shaved  or  cut  as  short  as  possible  with  scissors.  Short 
subcutaneous  tracts  should  be  laid  bare  by  connecting  the  wounds  of 
entrance  and  exit.  The  adjoining  skin  and  wound  should  be  swabbed 
with  a  50-per  cent,  solution  of  tincture  of  iodine,  followed  by  the  appli- 
cation of  a  first-aid  field  dressing.  In  field  and  base  hospitals  where 
all  the  facilities  for  wound  dressing  are  at  hand,  thorough  scrubbing 
with  nail  brush,  soap  and  water  and  the  liberal  use  of  antiseptic  solu- 
tions should  precede  the  application  of  the  primarj^  dressing. 

(b)  Shot  Wounds  of  the  Skull  without  Lesion  of  Cranial  Contents. 
— In  this  class  of  injuries  we  have  contusion  of  the  skull  with  fracture 
of  the  outer  or  inner  table  alone.  The  following  table  from  the 
Records  of  the  Civil  War  by  Otis  is  full  of  interest  for  a  consideration 
of  the  subject  of  cranial  injuries  by  gunshot  in  these  days  of  clean 
surgery  and  the  change  in  the  implements  of  war.  The  table  has 
served  all  writers  in  discussing  head  injuries  since  it  was  written, 
because  of  the  richness  of  the  material,  and  the  masterly  analysis  of 
it  by  the  great  author. 


GUNSHOT   WOUNDS    OF   THE    HEAD,    FACE    AND    NECK 


157 


GUNSHOT  INJURIES  OF  THE  CRANIUM 

Results  of  4350  Gunshot  Injuries  of  the  Cranium  Reported  During  the  War  of 

the  RebeUion 


Injuries 


Cases 


Recov- 
ered 


Died 


Undeter- 
mined 


Ratio  of 
mortal- 
ity i 


Contusions  of  the  skull 

Fracture  of  outer  table  alone  (?) 
Fractures  of  inner  table  alone. . . . 

Linear  fissure  of  both  tables 

Fracture  of  both  tables  without 
known  depression. 

Depressed  fractures 

Penetrating  fractures 

Perforating  fractures 

Ecrasement  or  crash  or  smash.  .  . 
Contre-coup  (?) 


328 

138 

20 

19 

2911 

3G4 

486 

73 

9 

2 


273 

128 

1 

12 

1001 

231 
68 
14 


55 

10 

19 

7 

1826 

129 

402 

56 

9 

1 


84 

4 

16 

3 


16.8 
8.7 
95. 
36.8 
64.6 

35.8 
85.5 
80. 
100. 
50. 


Aggregates 4350 


1729 


2514 


107 


57.7 


Contusion  of  the  Skull. — The  vast  majority  of  contusions  of  the 
skull  in  former  wars  were  inflicted  by  slow-moving  lead  rifle  bullets. 
The  change  of  the  armament  has  rendered  them  less  frequent  in  recent 
wars,  and  they  will  be  the  result  henceforth  of  impact  from  shrapnel 
balls,  slowly  moving  shell  fragments,  and  spent  rifle  balls.  In  such 
cases  the  periosteum  is  lacerated  and  the  bone  is  more  or  less 
contused. 

Fracture  of  Outer  Table  Alone. — Gunshot  fracture  of  the  external 
table  of  the  cranium  alone  has  been  especially  rare.  The  instances 
on  exhibition  in  the  vast  collection  of  skull  injuries  from  the  Civil 
War  in  the  U.  S.  Army  Medical  Museum,  at  Washington,  relate  to 
fracture  of  the  outer  table  of  the  frontal  sinus,  the  mastoid,  and  zygo- 
matic process  of  the  temporal  bone.  Now  and  then  a  grooving  of 
the  outer  table  of  the  vault  is  found  produced  by  the  sharp  angle  of  a 
shell  fragment.  Wherever  injury  to  the  outer  table  occurred  in  other 
regions  of  the  skull,  the  inner  table  was  also  involved.  What  was 
true  of  this  injury  by  the  old  armament  is  alike  true  of  the  same  injury 
by  the  new.  We  have  never  seen  a  gutter  fracture  of  the  skull  of 
the  outer  table,  from  jacketed  bullets  of  reduced  caliber  in  the  living, 
or  in  cadavers  from  experimental  shots,  which  did  not  show  splintering 


158  GUNSHOT   WOUNDS 

of  the  inner  table.  This  fact  has  also  been  noted  by  observers  in 
recent  campaigns  although  Stevenson  and  Makins  each  report  a  case 
from  the  Anglo-Boer  War. 

Fracture  of  the  Inner  Table  Alone. — Gunshot  fracture  of  the  inner 
table  alone,  occurring  from  direct  violence  to  the  outer  table,  has 
been  noted  by  military  surgeons  generally.  Otis  refers  to  ten  speci- 
mens in  the  Army  Medical  Museum  from  the  Civil  War  and  the  returns 
give  account  of  twenty  cases  in  all.  Figs.  87  to  90.  Makins  saw  no 
case  of  the  kind  in  the  Boer  War.  We  have  no  knowledge  of  such  an  in- 
jury by  the  jacketed  missiles  of  the  present  dsiy.  Of  the  twenty  cases 
reported  by  Otis  fourteen  were  caused  by  oblique  impact  of  musket  balls, 
four  by  shell  fragments,  and  one  by  a  buck  shot.  The  velocities  im- 
parted to  projectiles  in  that  day  compared  to  those  of  the  present  time 
were  low,  the  projectiles  themselves  were  non-penetrating,  obtuse 
bodies,  with  sufficient  energy  on  impact  to  cause  the  outer  table  to  yield 
temporarily  with  resulting  fracture  of  the  inner  table.  The  superior 
velocity  and  penetration  of  the  jacketed  rifle  bullets  of  the  present 
day  tend  to  fracture  the  outer  and  inner  tables  at  the  same  time, 
and  they  penetrate  the  skull  to  an  extent  proportional  to  the  amount 
of  their  remaining  energy. 

(c)  Gunshot  Fracture  of  the  Skull  with  Attendant  Brain  Injury.— 
In  this  class  of  wounds  the  inner  or  both  tables  have  been  fractured 
with  injury  to  some  of  the  cranial  contents  resulting.  They  are 
most  important  because  of  their  fatality;  the  prompt  and  radical 
measures  of  treatment  that  are  often  necessary;  and  also  on  account 
of  their  complications  and  sequelae. 

Fatality  of  gunshot  injuries  of  the  cranium  with  concurrent  brain 
injury  has  always  been  relatively  high.  Grouped  as  a  whole  in 
accordance  with  the  plan  in  Otis'  table,  the  fatality  in  the  Civil  War 
was  59.2  per  cent.,  in  the  Franco-German  War  51.3  per  cent.,  and  in 
the  Spanish- An;erican  War  and  Phihppine  Insurrection  51.6  per  cent. 

In  the  Anglo-Boer  War  Stevenson  gives  the  results  of  head  injuries 
as  follows: 


No.  cases 


Recovered        Died 


Death  rate 
per  cent. 


Gutters j         63         I         51         j         12         |       19 

Penetrations i         13         i  8  5  38.4 


Perforations . 
Totals.... 


60  37         '         23  38.3 


136         !         96         I         40         ;       29.4 


GUNSHOT   WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


159 


Fig.  87. — Photograph  of  outer  table  of 
skull  sho-wing  contusion  without  fracture 
by  a  conoidal  musket  ball. 


Fig.  88. — Inner  table  of  same  skull  with 
fracture.  A  fragment  an  inch  and  a  half  in 
length  and  half  an  inch  broad  completely  de- 
tached from  vitrious  table.  Specimen  from 
Civil  War  1861-65.     A.  M.  M.  collection. 


Fig.  89. — Photograph  of  gun-shot  con- 
tusion outer  table  of  skull  without  fracture 
by  a  conoidal  musket  ball. 


Fig.  90. — Inner  table  same  skull  showing 
fracture  with  depression  opposite  the  point  of 
contusion  on  outer  table.  Dura  was  lacer- 
ated. Specimen  from  Civil  War,  1861-65. 
A.    M.    M.  collection. 


160 


GUNSHOT   WOUNDS 


For  the  Russo-Japanese  War  Follenfant,^  writing  of  the  statistics 
in  the  Kharbine  hospitals  for  1904,  gives  a  mortahty  of  29.5  per  cent, 
in  seventy-one  gunshot  fractures  of  the  cranium  with  brain  lesion, 
and  a  mortality  of  10.2  per  cent,  in  263  fractures  without  brain  injury. 
Doubtless  the  latter  suffered  brain  lesion  in  a  certain  percentage  of  the 
cases  as  the  mortality  is  rated  too  high  for  this  class.  In  dwelling  upon 
the  rather  low  mortality,  29.5  per  cent,  and  29.4  per  cent.,  among 
those  who  suffered  with  brain  injury  in  these  two  recent  wars,  we  have 
to  remember  that  Kharbine  and  the  English  base  were  far  from  the 
front  and  that  the  statistics  are  culled  from  a  restricted  class.  Per 
contra  we  have  to  account  for  our  relatively  high  mortality,  51.6  per 
cent.,  in  the  Spanish- American  War  by  citing  the  fact  that  our  statis- 
tics were  made  up  from  all  cases  coming  under  treatment,  a  class 
without  restriction  as  to  time,  the  extent  or  location  of  injury.  We 
have  reason  to  believe  that  the  Anglo-Boer  War  and  Kharbine  statis- 
tics refer  only  to  cases  that  reached  hospital  care  after  the  lapse  of 
some  days. 

Gutter  Fractures. — This  form  of  injury  is  especially  common 
with  the  use  of  steel-jacketed  bullets.     The  ogival  headed  bullets  of 


Fig.  91. — Gutter  fracture  of  first  degree.     The  drawing  does  not  show  well  the  small  fragments 
of  bone  usually  carried  from  the  margins  of  the  depression  by  the  bullet.      (Makins.) 


this  class  travel  in  a  straight  line,  they  are  not  deflected  like  the 
old  lead  balls.  In  the  minor  degrees  of  guttering  the  outer  table 
is  grooved  by  the  projectile,  carrying  away  small  bone  fragments. 
As  these  particles  of  bone  become  displaced  with  great  violence 
they  take  up  part  of  the  energy  of  the  bullet  and  force  themselves 
1  Op.  cit. 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  161 

into    adjoining    soft   parts.     The    scalp    is    slit  in   superficial    bone 
fractures,  but  the  more  frequent  injuries  are  deeper,  they  exhibit 
oval   wounds   of   entrance   and   exit  which   mark   the  limit  of  the 
bullet's  track.     The   shock  of   impact   is  so  violent   in   the  deeper 
gutter  fractures  that  the  vibratory  force    invariably  fractures   the 
inner  table  and  the  amount  of  comminution  it  sustains  is  generally 
greater  than  that  seen  in  the  outer  table.     Gutter  fractures  of  the  type 
mentioned  occur  in  all  parts  of  the 
cranium,   they  are    characteristic  of 
jacketed    bullet    wounds,  and  under 
prompt  and  radical  measures  of  treat- 
ment the  prognosis  is  very  favorable 
for   head   cases.     The  following  dia- 
grams from    Makins    represent    the 
different  degrees  of  gutter  fractures 
and  superficial  perforating  fractures 
by  the  modern  bullet.      Figs.  91-96. 
Penetrating    Fractures. — In    this 
class    of    skull  fractures   there    is    a 
wound  of  entrance  and  no  apparent 

.  .  Fig.      92. — Diagrammatic       transverse 

wound    of  exit.       The  missile  is  gener-      sections    of  varying    condition  of  bones  in 

ally    lodged   within    the    skull  unless  it      S"^"^'"    f'-actures     of    tlie  first  degree.     A, 

with   no  loss   of   substance;  B,   with   com- 

has,    as   sometimes   happens,    passed    minution.    (Makins). 
down  the   neck.     Again  a  non-pene- 
trating lead    bullet,  impressed  by  low  velocity,  may  have  flattened 
and  lodged  against  the  skull,  producing  fracture  in  and  about  the  area 
of  impact,  or  it  may  have  bounded  back  through  the  entrance  wound 
in  the  scalp. 

Penetrating  fractures  were  more  common  in  the  days  of  the  old 
armament.  The  surgical  records  of  the  Civil .  War  make  note  of 
486  cases  with  a  mortality  of  85.5  per  cent.  The  majority  died  at 
once  or  soon  after  reaching  field  hospitals.  Many  cases  of  recovery 
with  lodged  balls  within  the  cranium  are  reported,  and  some  were 
reported  to  have  been  restored  to  duty  with  bails  lodged  in  their 
cerebrum,  "but  the  diagnostic  details  accompanying  the  histories  of 
these  cases  are  not  sufficiently  precise  to  invite  the  fullest  confidence" 
(Otis).  Missiles  were  successfully  extracted  from  within  the  cranium 
in  eleven  cases.  In  one  instance  the  wounded  was  an  officer  who 
remained  on  active  duty  ten  years  afterward,  while  the  others  were 
discharged  the  service  and  placed  on  the  pension  rolls. 

LIBRARY  OF  THE 

ALUMN!  ASSOCIATIOr 

COLLEGE  OF  PHYSiCIANB  ANDSURGti 
COLUMBIA  UNlvEI^Sil  V 


162 


GUNSHOT   WOUNDS 


Fig.  93. — Gutter  fracture  of  the  second  degree.     Perforating  the  skull  in  the  center  of  its  course. 
External  table  alone  carried  away  at  either  end.      (Makins.) 


Fig.  94. — Diagrammatic  transverse  sections  of  complete  gutter  fracture.  A,  external  table 
destroyed,  large  fragment  of  internal  table  depressed.  (Low  velocity  or  dense  bone.)  B,  comminu- 
tion and  pulverization  of  both  tables  center  of  track.  C,  Depression  of  inner  table  (low  velocity). 
(Makins.) 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


163 


Of  thirteen  cases  of  penetrating  gunshot  fractures  reported  by 
Stevenson  from  the  Anglo-Boer  War  the  bullet  lodged  in  nine  cases, 
with  five  deaths.  Of  the  four  who  recovered,  the  bullet  was  extracted 
in  three  cases  and  remained  lodged  in  one  case.  The  latter  is  referred 
to  as  a   "surgical  curiosity."     ''Trooper   ^I  was  admitted  to  No. 


/ 

J^^ 

^ 

^ 

, 

"^•'>'»- 

..vF 

Fig.  95. — Superficial  perforating  fracture.     Illiistrating  lifting  of    roof  at  both  entry    and  exit 

openings.      (Makins.) 

13  General  Hospital  for  a  gunshot  wound  of  the  scalp.  A  shell  had 
exploded  within  a  few  ysLrds  of  him,  and  he  believed  he  was  hit  on  the 
forehead  T\-ith  a  stone,  but  this  proved  to  be  incorrect.  There  was  a 
small  dry  scab  over  the  middle  of  the  frontal  bone,  and  beneath  it  an 
almost  healed  wound  through  which,  however,  a  probe  passed  into 


Fig.  96. — Diagrammatic  longitudinal  section  of  fracture  shown  in  Fig.  95.      (Makins.) 

the  cranial  cavity.  There  were  no  brain  symptons,  and  the  man  ex- 
pressed himself  as  being  "perfectly  well."  Brain  symptoms  appeared 
on  the  sixth  day;  the  temperature  went  up,  the  patient  became  very 
restless  and  quite  unaccountable  for  his  actions.  A  trephine  was 
applied  at  the  side  of  the  wound;  the  dura  was  found  lacerated; 
several  loose  pieces  of  bone  were  removed,  and  a  drain  put  in.     All 


164 


GUNSHOT   WOUNDS 


sjanptoms  disappeared  and  the  case  did  well  until  the  sevententh 
day.  Signs  of  brain  irritation  then  again  set  in,  and  there  was  evidence 
of  pus  under  the  scalp  above  the  right  ear;  the  scalp  was  incised, 
giving  exit  to  a  considerable  quantity  of  pus.  It  was  then  discovered 
that  there  was  a  fracture  of  the  skull  at  this  situation  and  that  the 
pus  came  from  an  abscess  of  the  brain.     The  trephine  was  again 


Fig.  97. — Latest  skiagram  of  John  Gretzer  showing  present  location  of  Mauser  btillet  in  brain. 
Exposure  made  in  1912,  thirteen  years  after  injury.  Army  Med.  School  collection,  Gibbs  Labor- 
atory.     Dr.  Leon  T.  LeWald,  X-rayist. 

applied,  the  abscess  washed  out  and  drained;  complete  recovery 
followed.     A  skiagram  showed  a  rij&e  bullet  at  the  base  of  the  brain." 

The  following  case  from  the  Spanish-American  War  is  of  even 
greater  interest  since  it  is  accompanied  by  a  photograph  and  skiagram 
recently  taken. 

"Case  14. — Penetrating,  Mauser-bullet  wound  of  brain;  wound 
aseptic;  bullet  not  removed. 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


165 


"John  Gretzer,  Jr.,  private,  Company  D,  First  Nebraska  Volunteer 
Infantry,  wounded  at  long  range,  March  27,  1899,  at  Mariboa,  Philip- 
pine Islands,  bj^  a  Mauser  bullet  entering  cavity  of  cranium,  3/4  inch 
above  the  supraorbital  ridge  and  1/4  inch  to  the  left  of  the  median 
line.  There  was  total  loss  of  consciousness  during  first  few  hours 
following  receipt  of  the  traumatism,  with  the  exception  of  a  few 
short  intervals  of  semiconsciousness,  at  which  time  excruciating  pain 


Fig.  98. — Photograph  of  John  Gretzer,  Jr.,  late  Pvt.  Co.  "  D,  "  1st  Neb.  Vol.  Inf.,  taken  thir- 
teen years  after  receipt  of  injury.  Scar  from  wound  entrance  shows  on  forehead  above  inner 
canthus,  left  eye.     Army  Med.  School  collection. 

in  the  head  was  experienced.  The  patient  was  taken  to  the  First 
Reserve  Hospital  at  Manila,  where  he  lay  in  bed  for  about  four  weeks. 
While  in  bed,  he  suffered  extremely  from  pain  in  the  head,  most 
severe  the  first  three  days,  moderating  slightly  at  the  end  of  the 
fifth  week,  becoming  intermittent,  greatly  exaggerated  on  exertion, 
by  heat,  and  especially  by  direct  rays  of  the  sun,  exposure  to  which 
caused  him  to  reel,  stagger,  and  almost  lose  consciousness.  At  the 
present  time  (August,  1899),  is  still  quite  susceptible  to  direct  rays 


166  GUNSHOT   WOUNDS 

of  the  sun.  First  few  days  of  illness  were  marked  by  extreme  nausea 
and  persistent  vomiting;  the  slightest  thing  taken  in  the  stomach 
would  be  rejected.  The  pain  in  the  head  increased  the  severity 
of  these  attacks.  During  early  weeks  of  illness  any  exertion  of  the 
brain,  as  reading,  caused  pain  in  back  of  eyes  and  vertex  of  the  head. 

''Returned  to  San  Francisco  with  his  regiment  in  August,  1899. 
Radiograph  taken  August  20  showed  Mauser  bullet  embedded  in 
left  occipital  lobe." 

"Condition  October  1,  1899,  six  months  after  receipt  of  the 
injury:  Occasionally  has  pain  in  the  lumbar  region,  and  describes  it 
as  being  a  "catch,"  lasting  about  five  minutes  at  a  time.  Pain  in 
the  head,  when  present,  is  located  a  little  anterior  to  parietal  eminence 
on  left  side.  There  is  no  history  of  loss  of  power  on  either  side,  but 
a  weakness  is  appreciated  in  the  right  arm  and  leg,  and  a  slowness  in 
response  to  mental  impulse.  This  last  is  demonstrated  in  the  act  of 
writing;  though  the  thought  is  perfectly  clear,  there  is  a  slowness  in 
the  forming  of  the  words." 

"Voice:  Patient  did  not,  to  his  knowledge,  exercise  this  function 
for  first  two  days  of  illness,  but  on  beginning  to  do  so,  noticed  a  slight 
confusion  of  ideas,  it  being  necessary  to  first  clearly  fix  a  thought  before 
giving  expression.  There  was  also  temporary  loss  of  power  to  recall 
past  events  and  names  of  companions.  This  returned  with  full 
clearness  at  other  times.     A  slight  confusion  still  remains." 

"Eye:  Pain  back  of  left  eye  more  or  less  severe,  and  increased  by 
use,  and  relieved  by  closing  the  lid.  During  confinement  to  bed 
following  injury,  patient  tested  vision  of  left  eye  by  closing  right. 
The  vision  was  clear,  but  slight  weakness  and  photophobia  were 
noticed.  Ptosis  of  left  eye  was  marked  during  early  weeks  of  illness. 
Aperture  is  now  smaller  than  that  of  right  eye.  A  slight  diplopia 
was  also  present,  a  line  of  printing  appearing  double.  Pupils  are 
regular,  but  left  slightly  larger.  Reaction  to  light  and  power  of 
accommodation  is  noticeably  decreased,  especially  in  left  eye.  Visual 
field  normal.     No  nystagmus." 

"Hearing  is  normal.  Sense  of  taste  more  acute  on  right  side,  the 
anterior  two-thirds  of  left  side  showing  marked  dullness. 

Tactile  sense  seemingly  slightly  dull  on  right  side.  General  sensa- 
tion of  right  side  not  as  acute  as  on  opposite  side. 

"Reflexes:  Knee  reflex  very  marked  on  right  side,  responding  to 
touch  above,  as  well  as  below  the  joint;  the  contact  from  finger  causing 
a  disagreeable  tingling  throughout  the  thigh.     On  left  side,  reflex  is 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  167 

exaggerated,  but  not  to  such  a  marked  extent.  Wrist  reflex  marked 
on  right  side,  causing  a  chronic  spasmodic  contraction  of  the  fingers. 
Reflex  absent  on  left  side.  Ankle  clonus  and  patellar  reflex  absent. 
Cremasteric  marked  on  both  sides.  Sphincters  uninvolved  at  any 
period  of  illness;  coordination  good,  though  a  slight  uncertainty  is  felt 
on  attempting  to  walk  -^dth  the  eyes  closed.  No  epileptiform  seizures. 
No  disturbance  of  nutrition  or  bodily  functions. 

The  patient  later  entered  the  mail  service  and  returned  to  Manila 
on  duty." — Reported  by  Major  A.  C.  Girard,  Surgeon,  United  States 
Army,  General  Hospital,  Presidio. 

Mr.  Gretzer  is  now  employed  as  a  clerk  in  the  Postoffice  Depart- 
ment.    In  a  recent  letter  he  writes  of  his  condition  as  follows: 

Postoffice  Department, 
Office  of  the  Inspector  in  Charge, 
New  York,  N.  Y.,  Oct.  13,  1911. 
Colonel  Louis  A.  La  Garde, 

Commandant,  Army  Medical  School, 
Washington,  D.  C. 
My  dear  Sir: 

I  am  in  receipt  of  your  favor  of  the  9th  inst.  relative  to  gunshot 
wound  of  head,  received  by  me  during  my  army  service  in  the  Philip- 
pine Islands.  I  regret  that  I  am  unable  to  furnish  you  with  a  medical 
historj^  of  my  case  since  leaving  the  Presidio  General  Hospital. 

I  have  not  received  medical  treatment  for  my  wound,  as  I  realized 
aside  from  an  operation  but  little  relief  could  be  afforded,  and  my 
condition  has  not  justified  that,  inasmuch  as  a  consultation  of  army 
surgeons  at  the  Presidio  Hospital  decided  that  an  operation  would 
probably  prove  fatal.  The  symptoms  from  which  I  suffer  as  a  result 
of  bullet  carried  in  brain  are  about  the  same  as  when  discharged,  except 
stooping  causes  severe  pains  in  the  head.  This  is  also  true  of  a  sudden 
jar.  My  wound  appears  to  be  affected  by  a  change  in  weather. 
General  health  good. 

I  will  be  pleased  to  furnish  you  any  further  information  desired, 
and  appreciate  the  interest  you  have  taken  in  my  case.  I  am 
enclosing  a  couple  of  newspaper  clippings  in  connection  with  my  case, 
which  may  be  of  interest. 

Yours  sincerely 

(signed)  John  Gretzer,  Jr. 


168  GUNSHOT   WOUNDS 

The  following  case  exhibiting  a  lodged  Krag-Jorgensen  bullet  is 
taken  from  the  records  of  the  hospital  Madison  Barracks,  New  York: 
J.  S.  Powell,  Pvt.  ''K"  Company,  9th  U.  S.  Infantry,  aet.  28,  admitted 
July  23,  1903.  "Accidentally  shot  by  firing  party  at  500  yards  range, 
ball  ricocheting  on  butt  timber  and  striking  patient  while  in  target  pit 
at  Stoney  Point  Rifle  Range,  New  York,  July  23,  1903,  as  per  transfer 
slip." 

Diagnosis  at  Hospital. — "Gunshot  fracture  skull,  right  parietal 
region,  Krag-Jorgenson  bullet,  severe,  causing  partial  hemiplegia, 
left  side.  Entrance  wound  4  inches  above  right  external  auditory 
meatus  and  4  inches  from  right  external  angular  process  of  frontal 
bone,  ball  penetrating  brain,  no  exit  wound."  Under  chloroform 
anesthesia  numerous  pieces  of  bone  were  taken  from  the  entrance 
wound,  a  bleeding  vessel  was  ligated;  brain  lacerated,  bullet  not 
found.  Scalp  wound  was  sewed  with  silkworm  gut  and  dressed  anti- 
septically.  Sent  to  quarters  August  23.  The  patient  was  later 
discharged  the  service,  but  he  was  readmitted  to  the  same  hospital 
June  3, 1904,  for  cerebral  abscess  posterior  part  parietal  lobe.  He  died 
the  same  day.  At  autopsy  ball  was  recovered  on  the  tentorium  in 
the  position  indicated  in  the  skiagram,  Fig.  99.  After  discharge  from 
the  service  Jan.  28,  1904,  the  patient  suffered  from  partial  paralysis 
left  side  face,  and  left  hand;  headache,  and  vertigo,  for  which  he  was 
borne  on  the  pension  rolls  until  his  death  June  3,  same  year. 

The  vital  parts  of  the  brain  are  sensitive  to  all  projectiles,  large  or 
small.  The  following  case  exhibits  the  effects  of  a  diminutive  bullet 
impressed  with  comparatively  low  velocity  when  traversing  the  brain 
at  the  base: 

Fig  100  is  from  a  skiagram  which  shows  a  .22-caliber  lead  bullet 
lodged  in  the  brain  substance.  It  was  fired  from  a  target  rifle  with 
suicidal  intent  by  Corpl.  C.  29th  Company  Coast  Artillery  Corps, 
U.  S.  Army.  The  muzzle  was  held  against  left  temple.  The  ball 
entered  2  cm.  above  middle  of  left  zygoma;  traversed  the  left  tem- 
poral lobe,  left  cms,  corpus  callosum  and  right  parietal  lobe,  re- 
bounding from  right  parietal  bone,  it  lodged  into  the  posterior  horn 
of  the  right  ventricle.  The  original  cartridge  was  a  .22  short  rim-fire 
lead  bullet,  weight  29  grains,  velocity  of  969  f.s.  The  deformed  bullet 
as  shown  in  Fig.  100  weighs  27  grains.  The  patient  never  regained  con- 
sciousness and  died  in  five  hours  from  compression  due  to  hemorrhage. 

Perforating  Fractures. — These  fractures  are  extremely  fatal  in 
war.     The  majority  of  the  cases  never  live  to  reach  field  hospitals. 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  169 

Otis  fixes  the  mortality  of  those  treated  in  the  hospitals  in  the  Civil 
War  at  80  per  cent.  Of  seventy-three  cases  only  fourteen  survived 
to  be  discharged  and  placed  upon  the  pension  rolls.  It  goes  without 
saying  that  the  fatality  of  perforating  fractures  of  the  skull  is  as  great 
to-day  with  the  use  of  the  present  armament  when  the  ball  traverses 
the  vital  parts  of  the  brain  as  it  was  formerly  with  the  old  armament. 
At  the  battle  of  Santiago  we  found  that  the  shots  traversing  the  pos- 
terior   two-thirds  of    the    skull  vertically,  obliquely,  or  transversely 


Fig.  99. — Skiagram  in  case  of    Pvt.  J.  S.  Powell,  Co.  "K"  9th  Inf.,  showing   a    Krag-Jorgensen 
bullet  lodged  on  the  tentorium.     Army  Med.  School  collection  X-ray  Laboratory. 

near  the  base,  were  uniformly  fatal,  and  that  the  amount  of  lesion 
and  fragmentation  were  proportional  to  the  remaining  velocity  and 
energy  of  the  bullet. 

The  so-called  explosive  effects  of  the  modern  mihtary  rifle  are 
strikingly  exhibited  in  perforating  fracture  from  proximal  shots 
on  the  skull.  Explosive  effects  have  often  been  reproduced  ex- 
perimentally on  inanimate  matter,  like   containers   of  tin   or  sheet 


170 


GUNSHOT    WOUNDS 


lead,  filled  with  water,  starch  paste,  etc.  In  the  human  body  the  skull 
with  its  rigid  walls  and  semifluid  contents  approaches  nearest  in  point 
of  resistance  to  the  containers  of  the  experimenters  and  the  force  which 
causes  the  remarkable  lesions  by  the  small  bullet  in  certain  wounds  of 
the  head  is  the  same  as  that  which  swells  and  forces  apart  the  walls 
of  the  containers.     (See  Figs.  69  to  74.) 

The  power  of  our  present  military  rifle  in  the  living  in  producing 
typical  explosive  effects  is  shown  in  a  case  of  suicide  recently  reported 

by  Lieut.-Colonel  Charles  Wilcox, 
Medical  Corps,  U.  S.  Army.  The 
present  bullet,  as  already  stated, 
is  jacketed,  pointed,  length  1.08 
inches,  30-caliber,  weighing  150 
grains,  initial  velocity  2700  f.s., 
energy  at  the  muzzle,  2400  foot- 
pounds. The  weapon  ranks  among 
the  most  powerful  military  rifles  in 
present  use. 

Patrick  Dolan,  Co.  '^K"  27th 
U.  S.  Infantry,  shot  himself  Novem- 
ber 13,  1911.  The  muzzle  of  the 
piece  was  probably  held  in  his 
mouth  or  near  it  in  a  direction  from 
base  to  vertex  of  the  skull.  The  ex- 
tensive destruction  of  soft  parts 
obliterated  all  semblance  to  a 
wound  of  entrance  or  exit.  The 
photographs  show  extensive  destruction.  The  face  above  the  lower 
jaw;  the  entire  cerebrum  and  cranial  vault  were  blown  away.  ''The 
entire  squad-room,  especially  the  ceiling,  was  stained  with  blood 
and  fragments  of  brain."  The  reporter  very  properly  adds  "If 
this  body  had  been  found  on  a  battlefield  after  an  action  in  which 
artillery  fire  had  played  a  part  it  would  undoubtedly  be  assumed  and 
with  good  reason  that  the  head  had  been  carried  away  by  either  a 
large  projectile  or  a  large  fragment  of  the  same."  Figs.  100  and  102. 
In  the  case  cited,  doubtless,  the  force  of  the  expanding  gases, 
liberated  at  the  time  of  the  escape  of  the  bullet,  added  to  the  ex- 
plosive effects,  but  aside  from  the  pressure  exerted  by  the  gases  we 
know  that  the  energy  of  the  projectile  itself  as  well  as  that  of  the 
secondary  missiles,  like  pieces  of  bone,  dura  and  partiacles  of  brain 


Fig.  100. — 1.  A  .22  cal.  bullet  lodged  in 
brain  as  indicated  by  arrow.  2.  Photograph 
of  bullet  removed.  Army  Med.  School  collec- 
tion.    Lattermann  Hospital,  X-ray  Laboratory. 


GUNSHOT   WOUNDS    OF   THE    HEAD,    FACE    AND    NECK 


171 


matter,  which  became  animated  with  part  of  the  energy  of  the  pro- 
jectile at  the  time  of  impact,  assisted  materially  in  the  production 
of  destructive  effects. 

The  bone  lesion  in  a  transverse  shot  at  the  base  of  the  skull  at  an 
average  battle  range  is  exhibited  in  Fig.  103,  a  specimen  from  the 
Army  Medical  Museum,  which  shows  the  effects  of  an  experimental 


Fig.   101. — Photograph  showing  side  view  in  case  of  Patrick  Dolan.     Army  Aled.  School  collection. 
Ft.  Sheridan  X-ray  Laboratory. 

shot  in  a  cadaver  by  the  same  ammunition  as  that  noted  in  the  pre- 
ceding case.  The  bullet  was  impressed  with  the  simulated  velocity 
at  900  yards.  It  key-holed  in  the  head  of  the  barrel  of  saw-dust 
which  was  placed  behind  the  target.  In  turning  the  ball  struck  the 
inner  table  of  the  skull  side  on,  which  no  doubt  added  to  the  size  of 
the  wound  of  exit  in  the  scalp,  and  helped  to  fissure  and  comminute 
the  bony  vault  as  shown  in  the  figure.  There  was  extensive  lacera- 
tion of  brain  tissue  on  the  exit  side,  which  was  no  doubt  due  to  the 


172 


GUNSHOT   WOUNDS 


Fig.   102. — Posterior  view  of  Fig.  101. 


Fig.  103. — Photograph  shows  an  experimental  shot  fracture  of  skull,  of  cadaver,  brain  in  situ, 
by  the  pointed  bullet  .30  cal.  Springfield  rifle,  simulated  velocity  at  900  yards;  wound  of  entrance 
over  left  temporal  bone,  size  and  shape  of  bullet;  wound  of  exit  irregularly  round,  1  inch  diameter. 
No.  14180  Pathological  Series.     Specimen  from  the  A.  M.  M. 


GUNSHOT    WOUNDS    OF   THE    HEAD,    FACE    AND    NECK  173 

direct  transmission  of  part  of  the  bullet's  energy  to  the  brain  parti- 
cles which  were  themselves  shot  forth  with  violence  against  the  bone, 
thus  adding  to  the  destructive  effects.  The  skull  as  a  whole  shows 
more  fissuring  than  is  usually  seen  in  a  gunshot  fracture  with  the  re- 
maining velocity"  at  900  j^ards.     The  subject  was  past  sixty  years,  and 


Fig.   104. — Army  Medical  Museum  collection.     Xo.  10910  pathological  series. 

no  doubt  the  brittle  condition  of  the  bones  of  the  aged  figured  in  the 
amount  of  fragmentation.  In  war  the  subjects  are  young  men  as  a 
rule  and  the  bony  lesions  are  not  so  marked. 

Figure  104  shows  the  appearance  of  a  postero-anterior  injury  in 
thelliving,  near  the  vault,  by  the  Krag-Jorgensen  bullet  at  close 
range  in  the  case  of  a  prisoner  who  attempted  to  escape  from  the  guard. 
The  bullet  was   .30   calibers,   jacketed;   weight   220   grains,    ogival- 


174  GUNSHOT   WOUNDS 

headed  with  an  initial  velocity  of  2000  f.s.  It  is  the  Krag-Jorgensen 
bullet  which  was  used  by  the  U.  S.  Army  until  1906.^  The  victim 
was  90  feet  from  the  rifle  when  hit.  He  was  running  from  the  guard  at 
the  time.  The  wound  of  entrance  was  in  the  occiput  and  that  of  exit 
in  the  frontal  region  as  shown  in  the  figure.  ''After  passing  through 
the  man's  skull  the  ball  penetrated  a  tree  8  inches  in  diameter  and 
buried  itself  in  the  ground  2  feet.     The  man  lived  one  hour."     The 

wound  of  entrance  in  the  skin  presented  a  round  opening 

The   wound  of   exit  in  front 

was  larger  and  more  ragged.  The  integument  was  carefully  dissected 
off  and  the  bone  at  the  top  of  the  skull  found  extensively  fractured, 
the  parts  being  here  and  there  connected  by  fascia.  On  the  calvarium 
being  removed  the  surface  of  the  dura  mater  presented  a  state  of  in- 
tense congestion.     To  the  right  of  the  longitudinal  fissure  it  was  torn 

through  for  a  distance  of  about  4  inches On  removal  of 

the  coverings  the  convolutions  of  the  brain  were  made  prominent 
by  the  engorged  network  of  superficial  veins.  A  furrow  corresponding 
to  the  injury  of  the  dura  was  ploughed  through  the  right  hemisphere' 
in  the  region  of  the  superior  frontal  convolution  about  1/2  inch  deep. 
The  right  lateral  sinus  appeared  filled  with  blood  serum,  the  left  was 
normal.  After  removal  of  the  brain  the  cribriform  plate  exhibited 
comminuted  fracture;  one  or  two  slight  fissures  in  the  petrous  and 
squamous  portions  of  the  temporal  bone,  otherwise  the  bone  was 
intact." 

The  explosive  effects  would  have  been  more  marked  had  the 
projectile  entered  nearer  the  base  and  penetrated  where  the  maximum 
resistance  in  the  skull  was  located.  As  it  was  it  did  a  great  deal  of 
damage  but  it  escaped  with  sufficient  remaining  energy  to  penetrate 
8  inches  into  a  tree  and  2  feet  in  the  ground  where  it  was  found 
undeformed. 

While  we  were  testing  the  comparative  difference  between  the 
effects  of  the  large  and  small-caliber  bullets  in  1893, ^  we  shot  in  the 
skull  of  a  cadaver  with  the  .45-caliber  Springfield  rifle.  The  bullet 
weighed  500  grains  with  an  I.V.  of  1301  f.s.  Fig.  105  has  a  marked 
resemblance  to  the  preceding.  The  bullet  in  this  instance  entered  the 
frontal  bone  2.17  inches  above  the  middle  of  the  right  orbit,  impressed 
by  the  simulated  velocity  at  250  yards.     The  bone  lesion  shows  that 

1  The  Krag-Jorgensen  Rifle.  A  report  of  its  effects  on  the  skull  of  the  living, 
etc.,  by  A.  C.  Girard,  M.  C,  U.  S.  A.,  Jour.  Amer.  Med.  Assn.,  1895,  No.  25. 

2  Report  S.  G.  O.,  1893. 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


175 


the  explosive  effects  of  the  two  bullets  are  quite  similar  in  the  proximal 
ranges  in  the  dead  or  living.  The  deformed  .45-caliber  bullet  which 
caused  the  injury  is  shown  in  the  illustration. 


Fig.  105. — Photograph  of  skull.  (1)  Lower  orifice  marks  point  of  entrance  of  bullet.  (2. 
Upper  orifice  marks  point  of  exit  of  bullet.  (3)  Photo,  of  bullet  left-hand  side  of  figure.  No) 
10921   A.    M.    Museum   collection. 

The  following  is  a  familiar  example  of  gunshot  injury  involving 
the  frontal  lobe:  B.  C.  Barker,  Pvt.  Co.  C,  4th  Infantry,  was  shot 
with  a  Mauser  bullet  July  1  at  Santiago.  The  bullet  passed  through 
the  left  temporal  region,  comminuting  the  bone  extensively,  and  caused 
a  wound  of  exit  at  the  left  frontal  eminence.  Loose  fragments 
were  removed  a  few  days  thereafter  when  the  wound  was  found  to  be 
suppurating.  When  last  seen  before  discharge  there  was  healing  of 
wound,  no  cerebral  hernia.  Mind  was  clear  most  of  the  time,  occa- 
sional confusion  and  wandering,  March  18,  1912.  Mr.  Barker  is  now  a 
per  month  pensioner.     In  a  letter  written  by  him  March  16,  1912, 


176 


GUNSHOT   WOUNDS 


he  states  that  he  is  entirely  incapacitated  for  work.     Lifting,  stooping, 
overexertion  and  heat  bring  on  dizzy  spells. 

Makins,  referring  to  the  effects  of  the  reduced-caliber  bullet, 
found  vertical  and  coronal  perforations  in  the  frontal  region  common 
in  the  Anglo-Boer  War.  With  lower  velocities  simple  punctured 
fractures  in  entering  and  leaving  the  skull  were  noted  which,  as  in- 
dicated by  the  symptoms,  were  ''without  extensive  lesion  of  the 
frontal  lobes." 


Fig.   106. — A  recent  photograph  of  Mr.  B.  C.  Barker,  showing  the  scar  and  depression  of  skull  over 
the  left  frontal  region.     A.  M.  School  collection. 


Stevenson  refers  to  the  results  in  sixty  unselected  cases  of  per- 
forating fractures  of  the  skull  in  the  same  campaign  in  which  the  mor- 
tality was  38.3  per  cent.  As  compared  to  80  per  cent,  in  the  ninety- 
three  cases  in  the  Civil  War  reported  by  Otis,  the  reduction  in  fatal 
cases  is  most  marked. 

The  practice  of  modern  times  favors  operative  interference  in 
nearly  all  cases  of  gunshot  fracture  of  the  skull,  and  to  this  practice 
we  attribute  the  greater  ratio  of  recoveries.     At  the  same  time  that 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  177 


Fig.  107. — Skiagram  shows  bullet  of  the  .38  cal.  Colt's  revolver  lodged  under  the  skin  2.25  cm. 
above  the  posterior  occipital  protuberance.  Sgt.  V.  held  the  muzzle  of  the  revolver  near  his  head 
and  fired  with  suicidal  intent.  The  bullet  entered  5  cm.  above  bregma  near  center  of  frontal  bone. 
There  was  fracture  of  the  cranium  along  the  superior  longitudinal  sinus  from  wound  of  entrance 
to  point  of  lodgment  of  ball.  A  fracture  extended  downward  into  the  left  parietal  to  the  middle 
of  the  left  temporal  bone.  Another  fracture  extended  to  the  right,  to  upper  part  of  right  temporal 
bone  while  other  fractures  were  present  as  shown  in  skiagrams.  Superior  longitudinal  sinus  and 
upper  part  right  cerebral  hemisphere  badly  lacerated.  Patient  lived  but  25  minutes  after  he  was 
shot.  The  bullet  had  not  sufficient  energy  to  perforate  the  scalp.  Army  Med.  School  collection. 
X-ray  Laboratory.     Presidio    General   Hospital, 


Fig.  108. — Skiagram  showing  side  view  of  Fig.  107.     Army  Med.  School  collection. 


178 


GUNSHOT   WOUNDS 


lives  are  saved  in  larger  numbers  now,  there  are  sequelsB  and  compli- 
cations among  those  who  survive  that  are  most  distressing 

In  connection  with  the  subject  of  perforating  wounds  by  the 
military  rifle  bullet,  it  is  interesting  to  note  that  the  same  character 
of  lesion  will  occur  henceforth  from  pistol  bullets,  because  automatic 
pistols  which  fire  steel-jacketed  projectiles  are  becoming  part  of  the 
armament  of  the  nations  in  lieu  of  revolvers  which  employ  lead  bullets. 


Fig.  109. — Skiagram  showing  perforating  fracture  of  head  by  Colt's  new  service  revolver  .45 
cal.  lead  bullet  at  close  range  in  cadaver,  hrsiin  in  situ.  Ball  flattened,  lost  its  penetration  and  then 
lodged.     Note  particles  of  lead  in  track  of  bullet.     Army  Medical  School  collection. 

Hitherto  the  greater  number  of  gunshot  injuries  of  the  cranium  from 
revolvers  in  both  civil  and  military  practice  resulted  in  penetrating 
fractures  with  lodged  balls.  This  was  due  to  comparatively  low 
velocities,  and  the  great  tendency  of  the  lead  bullets  to  deform  on 
impact  against  the  hard  skull.  Even  in  the  proximal  ranges  the  bullet 
of  the  .45  and  .38-caliber  new  service  Colts  revolvers,  two  of  the  most 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


179 


effective  weapons  of  their  tj^pe,  and  which  were  recently  discarded 
by  our  army,  failed  to  perforate  the  skull  in  the  majority  of  cases. 
(See  Figs.  107,  108,  109.) 


Fig.  110. — Photograph  of  gun-shot  fracture  of  cranium  in  cadaver  with  brain  in  situ  by  the 
Luger  automatic  pistol  bullet,  cal.  7  65  mm.  at  37  1/2  yards,  with  velocity  of  1258  f  .s.  Bullet 
entered  left  orbit  and  emerged  above  and  behind  right  auditory  meatus  fracturing  left  malar,  orbital, 
surface  superior  maxillary,  ethmoid,  body  and  great  wing  of  sphenoid,  vomer;  separated  the  right 
malar,  fracturing  frontal  over  orbit,  right  parietal,  petrous  squamous  and  mastoid  portions  of  right 
temporal,  left  parietal  and  left  occipital  bones.     Philadelphia  Polyclinic,  service  of  Dr.  A.  Hewson. 

Jacketing  the  bullet  of  the  automatic  weapons,  and  the  use  of 
smokeless  powder,  have  added  to  the  penetration  and  velocity  of  the 


180  GUNSHOT    WOUNDS 

new  arm  to  such  an  extent  that  its  bullets  will  seldom  deform,  they 
will  lodge  less  often  in  the  tissues,  including  the  skull.  The  wounds 
of  the  cranial  region  will  be  of  the  yerjorating  kind  and  the  lesions 
will  more  nearly  approach  those  produced  by  the  military  rifle. 

Fig.  110  shows  the  amount  of  Assuring  which  results  from  the 
energy  of  these  powerful  pistols.  The  amount  of  fragmentation  is 
doubtless  increased  by  the  fact  that  the  shorter  bullet  is  unstable 
and  travels  at  a  tangent  to  its  line  of  flight  on  meeting  slight  resis- 
tance.    For  ballistics  of  pistols  and  revolvers,  see  pages  70-71. 

Remote  Effects  of  Head  Wounds. — The  disabling  consequences 
of  gunshot  injuries  of  the  head  are  very  common.  Longmore  in  his 
wide  experience  states  that  but  few  cases  of  head  injuries  from  gunshot, 
be  they  contusions  or  fracture,  fail  to  show  evidence  of  cerebral 
disturbance. 

Cicatrices  of  the  scalp  are  occasionally  painful  enough  to  require 
excision.  After  either  severe  injury  or  concussion  to  the  brain  there 
are  annoying  symptoms  such  as  headache,  dizziness,  irritability,  etc., 
which  are  noticed  in  convalescence  and  more  particularly  when  the 
patient  resumes  his  vocation.  In  many  cases  the  symptoms  persist 
and  in  some  they  become  worse.  Paralytic  symptoms  are  worse  at 
first  and  tend  to  disappear  wholly  or  in  part  with  time.  Symptoms 
like  the  latter  no  doubt  owe  their  presence  to  vibratory  disturbances 
and  small  parenchymatous  hemorrhages  which  tend  to  disappear  with 
the  process  of  repair,  and  they  are  at  their  worst  during  this  time. 
In  soldiers  they  are  prone  to  recur  when  on  duty  in  hot  climates. 
They  are  aggravated  by  the  use  of  alcohol.  Physical  and  mental 
endurance  are  often  undertaken  with  fatigue;  patients  are  disturbed 
by  trifles  and  sensitive  to  sensory  stimuli.  The  memory  may  be 
impaired,  patients  forget  names;  they  become  forgetful  through 
lack  of  attention.  Changes  in  character  may  be  seen;  those  who  were 
formerly  of  a  cheerful  disposition  become  eccentric,  irascible,  moody, 
and  fault-flnding.  Epilepsy  is  common,  and  insanity  has  been  noted. 
Destruction  of  specialized  areas  of  the  cortex  like  the  speech  center  are 
apt  to  remain  permanent. 

The  complications  of  gunshot  fracture  of  the  skull  are  concussion, 
compression  and  hemorrhage,  with  meningitis,  encephalitis,  hernia 
cerebri  and  brain  abscess  as  sequelae. 

Concussion,  Compression  and  Hemorrhage. — The  symptoms  of 
concussion  and  compression  are  difficult  to  differentiate  in  the  begin- 
ning unless  depressed  bone  is  apparent.     They  are  usually  accom- 


GUNSHOT   WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  181 

panied  by  unconsciousness  and  shock.  It  should  be  remembered 
that  concussion  per  se  is  rare  in  gunshot  of  the  skull,  while  compres- 
sion from  depressed  bone  or  hemorrhage  either  above  or  below  the 
dura  is  common.  Concussion  which  results  from  contusion,  guttering 
or  the  minor  injuries  to  the  skull  is  apt  to  be  transient.  In  penetrating 
or  perforating  wounds,  the  sj^mptoms  of  brain  injury  accompany  those 
of  compression  if  the  latter  be  present.  The  symptoms  of  compres- 
sion from  depressed  bone  occur  immediately  after  the  receipt  of  the 
injury,  while  the  symptoms  from  hemorrhage  are  more  apt  to  come 
gradually.  Hemorrhage  between  the  skull  and  dura  may  be  produced 
by  contusion  or  fracture.  The  middle  meningeal  or  some  of  its 
branches  are  usually  implicated  especially  if  the  bleeding  is  severe. 

Meningitis,  encephalitis,  hernia  cerebri  and  brain  abscess  are 
grave  symptoms  because  nearly  all  fatal  cases  of  gunshot  injury  of  the 
head  in  the  later  stages  die  from  one  or  more  of  these  complications. 
It  is  needless  to  state  that  they  all  arise  from  primary  infection  which 
is  prone  to  occur  in  head  wounds. 

Hernia  cerebri  is  one  of  the  common  and  very  fatal  complications 
of  gunshot  fracture  of  the  cranium.  It  results  from  rupture  of  the 
dura  in  fractures  of  the  skull  by  the  penetration  of  missiles  or  de- 
pressed fragments  of  bone.  It  may  be  primary  or  secondary.  In 
the  primary  form  there  is  usually  a  larger  opening  through  which  the 
brain  matter  escapes  beyond  its  normal  level,  at  the  time  of  the  injury. 
It  is  most  generally  the  result  of  pressure  exerted  by  internal  hemor- 
rhage. In  recent  wars  it  has  been  noted  as  an  accompaniment  of 
cranial  fracture  attended  with  explosive  effects  from  proximal  shots 
by  the  military  rifle.  The  secondary  form  results  from  intracranial 
pressure  which  may  be  exerted  by  an  abscess  or  by  the  products  of 
inflammation  as  in  meningitis  and  encephalitis.  Primary  cerebral 
hernia  is  nearly  always  fatal.  Otis  reports  fifty-five  cases  of  secondary 
cerebral  hernia  with  a  mortality  of  80  per  cent.  Stevenson  refers  to 
twelve  cases  in  the  Anglo-Boer  War  with  a  mortality  of  41.9  per  cent. 
In  the  Russo-Japanese  War  Lynch  reports  upon  the  frequency  and 
fatality  of  cerebral  hernias  in  the  Japanese  hospitals.  He  attributes 
their  frequency  to  the  large  openings  made  in  the  skulls  by  the 
Russian  surgeons.  The  protruded  mass  is  usually  covered  by  granu- 
lating tissue. 

Treatment  of  cerebral  hernia  consists  in  protecting  the  ulcerated 
surface  by  clean  dry  dressings  applied  with  moderate  pressure.  The 
parts  should  be  washed  daily  with  mild  antiseptic  solutions  and  gently 


182  GUXSHOT    WOUNDS 

dried  before  reapplication  of  the  dressing.  Absolute  alcohol  is 
recommended,  to  be  painted  on  the  growth  daily  for  its  cleansing  and 
dehydrating  effects.  Excision  and  cauterization  have  their  dangers 
but  they  have  been  attended  ^dth  success.  Skin  transplanting  and 
osteoplastic  repair  have  given  good  results  in  suitable  cases.  Gangrene 
and  spontaneous  separation  sometimes  result  in  cure.  The  stump  is 
covered  by  granulations  and  finally  healed  by  connective-tissue 
formation. 

Abscess  of  the  brain  as  a  complication  of  gunshot  fracture  of  the 
cranium  rarelj^  appears  earlier  than  the  tenth  day,  but  more  often 
during  the  second  and  third  weeks.  The  symptoms  are  nearlj^  alwaj's 
insidious  in  their  onset.  They  consist  of  slight  rise  of  temperature, 
headache,  chill,  nausea  and  vomiting,  drowsineiiS.  Jacksonian 
epileps}^  appears  in  some  cases,  also  irritability  of  temper.  Choked 
disc  is  a  fairly  constant,  and  slow  pulse  is  a  significant  symptom. 

When  abscess  is  suspected  exploration  with  a  hypodermic  needle 
or  small  trocar  should  be  practised  at  once,  and  when  pus  is  found  it 
should  be  evacuated,  and  the  abscess  cavity  irrigated  and  drained. 
The  abscess  will  usuallj'"  be  found  in  the  injured  area  but  not  necessarih' 
so.  In  anj^  event  it  should  be  sought  for  in  the  area  indicated  bj^  the 
localizing  symptoms. 

Treatment  of  gunshot  fractures  of  the  cranium  consists  in  prompt 
operative  interference  in  every  case  that  offers  any  hope  of  recovery. 
With  our  present  knowledge  we  know  that  the  expectant  attitude 
employed  in  the  dsLys  of  our  Civil  War  was  responsible  for  a  large 
number  of  deaths.  It  was  in  order  then  to  await  sjTiiptoms  and 
then  to  operate.  If  we  pursued  the  same  practice  to-day  our  results 
would  be  but  little  better  notmthstanchng  the  aid  which  we  receive 
from  antiseptic  treatment .  A  gunshot  fracture  of  the  cranium  is  in 
the  nature  of  a  punctured  wound  and  it  is  infected  primarily  by  the 
ball  and  skin  of  the  scalp  in  every  case.  Cases  in  which  the  ball  has 
traversed  the  brain  deeply  near  the  base,  and  those  cases  exhibiting 
long  bullet  tracks  vertically  or  transversely  except  in  the  frontal  lobes 
give  but  little  promise  of  relief  bj-  operation.  The  same  is  true  of 
gunshot  in  any  region  which  bears  evidence  of  explosive  effects  from 
proximal  shots.  In  the  latter  the  brain  and  bone  lesions  are  marked 
by  fissures,  lacerations,  and  brain  pulp  is  present  beyond  the  bullet's 
track.  Spiculge  of  bone  and  often  particles  of  metal  are  driven  into 
the  brain  substance,  causing  dangerous  wounds  in  themselves. 

The  time  for  operation  should  be  immediately  after  the  receipt  of 


GUNSHOT   WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  183 

the  injury,  because  delay  means  sepsis.  Of  the  cases  demanding 
attention  at  a  dressing  station,  the  head  cases  should  be  among  the  first 
selected.  Since  infection  is  about  the  only  danger  to  be  feared,  the 
greatest  precaution  should  be  taken  to  prevent  infection  from  the 
beginning.  To  that  end  the  scalp  should  first  be  shaved  and  cleansed. 
In  the  emergent  conditions  attending  battle  there  is  scarcity  of  water, 
as  a  rule.  Fortunately  tincture  of  iodine  or  Lugol's  solution  is  a  ready 
and  efficient  substitute  in  the  field  and  one  or  the  other  of  these  should 
be  applied  in  50  per  cent,  strength  to  the  whole  scalp  as  soon  as  it  has 
been  shaved  or  closely  clipped.  A  flap  should  next  be  raised  at  the 
wound  of  entrance  with  its  convexity  directed  in  the  best  way  to 
promote  drainage,  the  bullet  opening  forming  the  center  of  the  raised 
flap.  If  the  opening  in  the  skull  is  not  sufficiently  large  to  permit 
thorough  exploration  space  can  be  gained  by  the  use  of  the  rongeur. 
Loose  fragments  under  the  scalp  and  those  driven  in  and  about  the 
entrance  wound  should  be  sought  for  and  removed.  It  is  well  to 
explore  the  channel  in  the  brain  for  2  inches  or  more  for  lodged  pieces 
of  bone,  the  bullet,  or  pieces  thereof.  All  fragments  and  foreign  bodies 
having  been  removed,  the  disintegrated  brain  pulp  and  blood  clots  are 
carefully  washed  away.  The  scalp  wound  is  then  closed  by  suture 
without  drainage.  The  latter  can  be  secured  most  reachly  at  any 
subsequent  time  if  necessarj^  The  surgeons  in  recent  campaigns 
insist  upon  the  value  of  primary  union,  an  outcome  which  so  readily 
insures  against  the  occurrence  of  complications  of  a  fatal  or  annoying 
nature.  The  wound  of  exit,  if  it  shows  marked  lesion,  should  be  treated 
likewise.  The  less  severe  cases  seldom  requires  more  than  cleaning  and 
a  primary  dressing.  Gutter  fractures  wherein  the  floor  of  the  gutter  is 
formed  by  the  fragmented  inner  table  should  be  freed  of  fragments 
and  the  edges  of  the  two  tables  made  smooth  by  rongeur -forceps.  De- 
pressed fractures  without  perforation  should  be  explored  and  the  de- 
pressed fragments  replaced.  Fragments  of  the  inner  table  which  make 
pressure  on  the  dura  or  brain  should  be  removed  entirely  It  is  a  safe 
rule  to  explore  all  gunshot  wounds  of  the  cranium  whether  fracture  is 
apparent  or  not.  In  cases  of  doubt  no  harm  can  come  from  removing 
a  hah-inch  crown  of  skull  near  the  point  of  impact,  for  the  purpose  of 
exploration.  Such  a  practice  is  prompted  by  the  number  of  cases 
which  are  related  in  all  works  on  military  surgery  of  apparently  trivial 
contusions,  which  later  terminated  disastrously  from  injury  to  the 
brain  or  its  membranes.  In  this  connection  we  should  remember  that 
gunshot  wounds  differ  from  wounds  by  other  offending  bodies  in  that 


184  GUNSHOT   WOUNDS 

the  missile  is  usually"  animated  by  an  amount  of  eoergy  which  is 
often  dissipated  in  the  produoction  of  fractures  that  are  not  always 
apparent  to  the  sense  of  touch  or  sight. 

The  treatment  above  indicated  was  faithfully  followed  by  the 
British  surgeons  in  the  Anglo-Boer  War.  The  army  was  accompanied 
b}^  celebrated  clinicians  who  carried  out  the  policy  of  early,  thorough 
and  careful  exploratory  work  in  all  head  cases.  The  consequence  was 
that  their  average  mortality  in  sixty-three  gutter,  thirteen  penetrat- 
ing and  sixt}^  perforating  fractures  of  the  cranium  was  only  29.1  per 
cent.  The  boldness  and  forethought  of  the  British  surgeons  is  well 
worth}^  of  emulation.  No  doubt  their  example  will  be  a  factor  in  the 
reduction  of  the  fatality  of  head  wounds  in  the  wars  of  the  future. 
The  same  plan  of  treatment  was  observed  in  the  Manchurian  campaign, 
according  to  Dr.  V.  Oettingen.^  The  value  of  early  operation  to 
ward  off  abscess,  meningitis,  etc.,  was  carried  out  promptty.  He  in- 
troduced his  finger  covered  with  a  rubber  glove  deep  into  the  wounds 
to  cleanse  them  of  all  bone  and  metallic  fragments. 

Removal  of  Lodged  Missiles. — Attempt  to  remove  foreign  bodies 
like  bullets  or  pieces  of  shell  from  the  brain  are  to  be  discouraged 
unless  the  indications  are  prompted  by  easy  access,  as  shown  by  the 
Rontgen-ray  plate,  or  by  very  annoying  symptoms.  Past  experience 
discourages  the  practice  of  prolonged  search  for  balls,  which  more 
often  ends  in  failure  and  the  infliction  of  wounds  more  dangerous  than 
the  presence  of  the  foreign  bocty  itself.  The  inconveniences  of  a  ball 
buried  in  the  brain  are  not  sufficient  to  warrant  the  risks  of  operation, 
as  a  rule.  Fortunately  lodged  missiles  from  the  present  armament 
will  rarely  occur  because  of  the  superior  penetration  of  the  jacketed 
bullets.  Furthermore,  the  reduction  in  weight  of  military  rifle  bul- 
lets from  500  to  150  grains  will  be  attended  with  fewer  and  less  severe 
symptoms  from  lodged  missiles  in  the  brain  than  have  been  noted 
heretofore. 

(2)  Gunshot  Wounds  of  the  Face. — Gunshot  wounds  of  the  face 
have  their  chief  interest  in  the  disfigurement  which  follows  injuries 
by  shell  fragments  and  large-caliber  rifle  bullets.  The  mortality  of 
face  wounds  has  never  been  high.  Secondary  hemorrhage  and  sup- 
puration extending  to  the  meninges  from  necrosis  of  bone  and  lodged 
balls  embedded  in  the  spongy  bones  of  the  nasal  and  supramaxillary 
regions  were  the  chief  causes  of  death  in  preantiseptic  times.  Among 
2276  gunshot  injuries  entered  on  the  U.  S.  Army  registers  for  1899 

1  Munch.  Med.  Wochens,  1906,  No.  7,  p.  218. 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


185 


from  all  kinds  of  missiles  there  were  twenty-seven  fractures  of  the  bones 
of  the  face  with  two  deaths. 

The  character  of  wounds  from  shell  fragments,  shrapnel  and 
large-caliber  rifle  bullets  is  the  sam.e  to-day  as  formerly  and  in  spite 
of  our  best  endeavor  deaths  still  occur  from  inflammation  extending 
to  the  meninges  and  brain.  The  absence  of  disfigurement  from  shots 
by  the  modern  military  rifle  bullet  beyond  the  proximal  ranges  is  one 
of  the  striking  evidences  of  the 
beneficence  which  comes  from  the 
use  of  the  new  arm. 

Wounds  of  the  Ear. — Wounds 
through  the  pinna  are  slit -like  and 
heal  rapidly.  Shots  in  and  near 
the  external  auditory  meatus  are 
apt  to  end  in  paralysis  of  the 
seventh  nerve  and  deafness  as  a 
result  of  vibratory  concussion. 

Wounds  of  the  Orbit. — Are 
common  and  serious  to  vision. 
Transverse  shots  are  the  most  seri- 
ous as  thej^  are  prone  to  injure 
both  eyes.  Aside  from  direct  trau- 
matism to  the  globe  or  optic  nerve 
itself,  blindness  has  frequently  been 
observed  in  recent  wars  from  vibra- 
tory impulses  on  impact,  causing 
minute  hemorrhages  from  rupture 
of  choroidal  vessels.  In  such  cases 
unless  vision  returns  soon  after  the 
receipt  of  the  injury  the  prognosis 
is  bad.  In  the  case  of  an  officer 
who    received    a    transverse    shot 

from  a  Mauser  bullet  at  Santiago  just  beneath  the  orbits,  it  is  at 
present  impossible  to  detect,  on  careful  inspection,  the  scars  which 
mark  the  location  of  the  wounds  of  entrance  and  exit.  The 
author  had  this  officer  for  a  patient  a  few  days  after  he  was 
wounded,  and  he  has  served  with  him  for  two  years  since,  on  his  offi- 
cial staff,  but  he  cannot  recall  any  visible  disfigurement  from  the 
effects  of  the  wounds.  The  left  eye  was  injured  at  the  time,  causing 
total  blindness,  so  that  it  was  subsequently  enucleated,  and  the  vision 


Fig.  111. — Skiagram  shows  .22  cal.  bullet 
lodged  in  orbit.  Army  Med.  School  collection. 
From  Lettermann  Genl.  Hospital. 


186  GUNSHOT    WOUNDS 

in  the  right  eye  remains  slightly  impaired  as  a  result  of  vibrator}- 
concussion. 

Fig.  Ill  shows  the  dangers  of  the  .22-caliber  target  practice  ammu- 
nition so  much  used  in  this  country  for  sporting  purposes,  and  also 
used  in  our  army  for  gallery  practice.  Private  Frank  Piaski,  Co.  H, 
30th  Infantry,  was  shot  while  in  target  pit  March  28,  1910,  with  a  .22- 
caliber  (short  commercial)  cartridge,  the  bullet  entering  the  right  eye 
just  above  the  inner  canthus,  resulting  in  total  blindness  in  the  injured 
eye.  As  seen  in  the  figure  the  ball  lies  lodged  in  the  back  part  of  the 
orbit  and  its  path  is  marked  by  a  stream  of  lead  particles.  The  latter 
would  indicate  that  the  ball  was  deformed  on  being  deflected  by  the 
frontal  bone  at  the  lower  and  internal  end  of  the  superciliary  ridge 
where  the  bone  is  thick,  and,  having  lost  its  momentum,  it  lodged  as 
shown  in  the  skiagram. 

Wounds  of  the  Nose. — The  cartilages  of  the  nose  like  those  of  the 
pinna  of  the  ear  suffer  slit-like  wounds  that  heal  readily.  In  the  case 
of  an  officer  at  the  battle  of  Santiago,  whose  case  has  already  been 
referred  to  under  the  subject  of  multiple  wounds,  the  ball  perforated 
the  soft  parts  of  the  cheek,  then  passed  through  the  cartilages  of  the 
nose  in  and  out  in  a  transverse  direction.  The  wounds  were  trifling 
in  their  nature  and  he  preferred  to  return  to  the  line  rather  than  suffer 
shipment  home  with  other  wounded.  Wounds  of  the  nasal  fossae 
have  been  known  to  destroy  the  sense  of  smell,  most  likely  as  a  result 
of  vibratory  impulse. 

Wounds  of  the  Malar  Bones. — The  malar  bones  are  the  most 
resistant  bones  of  the  upper  part  of  the  face  and  shots  received  in  the 
explosive  zone  are  apt  to  be  attended  with  fissuring  and  displacement 
of  bone  fragments,  causing  lacerations  which  in  turn  augment  the 
tendency  to  inflammation.  In  the  mid  and  remote  ranges  the  bone 
lesion  takes  the  nature  of  a  perforation. 

Wounds  of  the  Upper  Jaw. — Are  apt  to  include  the  antrum, 
buccal  cavity,  alveolar  process  and  teeth.  The  latter  are  often 
displaced  with  violence,  causing  lacerations  which  are  painful  and 
heal  slowly.  Lt.  W.  S.  W.,  9th  Cavalry,  was  shot  by  a  Mauser  bullet 
at  Santiago  July  1.  The  bullet  entered  the  lower  lip  near  the  right 
angle  of  the  mouth,  causing  loss  of  four  teeth  in  the  lower  jaw  and 
fracture  of  the  four  upper  incisors  and  right  upper  molar.  It  was  here 
deflected  and  passed  under  the  inferior  maxilla  and  lodged  in  the 
left  sterno-cleido-mastoid.  There  were  lacerations  in  the  mouth 
and  tongue  causing  much  pain  and  discomfort  with  attendant  in- 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  187 

flammation  which  extended  down  the  neck.  The  bullet  was  removed 
from  the  substance  of  the  sterno-cleido-mastoid  about  its  middle  at 
Soldiers  Home  Hospital,  D.  C,  in  October,  1898. 

Balls  penetrating  the  buccal  cavity  often  groove  or  perforate  the 
tongue,  but  they  seldom  lodge  in  its  substance.  Figs.  112  and  113 
show  an  improvised  Filipino  bullet  from  a  ]\Iauser  rifle  which  we  re- 
moved from  the  base  of  the  tongue  and  Fig.  114  shows  a  jacketed  bullet 
lodged  in  the  antrum. 

Wounds  of  the  Lower  Jaw. — When  the  mandible  is  struck  by  a 
high-velocity  bullet,  its  compact  substance  splinters  readily,  causing 


Fig.  112  Fig.  113 

Fig.  112. — Radiograph  of  G.  W.  G.,  showing  lead  slug  lodged  in  base  of  tongue.  The  ball 
entered  behind  the  left  ear.  Radiograph  taken  fourteen  months  after  injury.  Remote  effects: 
Left  hemiparalysis  of  tongue  also  loss  of  taste  on  left  side;  loss  of  hearing  in  left  ear;  left  optic  neuritis; 
partial  anchylosis  of  lower  jaw  and  painful  deglutition.  The  bullet  was  removed  Oct.  4,  1900.  The 
painful  deglutition  was  completely  relieved.  Photo  of  bullet  is  shown  in  Fig.  113.  Army  Med. 
School  collection.     U.  S.  Soldiers  Home  X-ray  Laboratory.     Dr.  A.  B.  Herrick,  X-rayist. 

corresponding  damage  to  soft  parts.  The  traumatism  is  greater 
still  when  teeth  are  displaced  from  the  alveolar  process.  In  the 
mid  and  remote  ranges  the  small  jacketed  bullet  is  apt  to  gutter  or 
perforate  the  bone  -^dth  little  splintering.  Fractures  of  the  upper 
part  of  the  ascending  ramus  and  neck  of  the  condyle  are  often  at- 
tended with  comminution  and  are  apt  to  cause  anchylosis  unless 
properly  explored  at  the  time. 

Treatment. — In  wounds  of  the  orbit  with  brain  injury,  if  the  bullet 
has  passed  from  the  orbit  to  the  brain  it  is  preferable  to  enucleate  the 
eye  at  once  and  remove  such  spiculse  of  bone  as  may  be  necessary 
from  the  wound  of  entrance  in  the  roof  of  the  orbit.  In  all  other 
cases  with  concurrent  brain  injur}-  in  which  the  globe  has  been  de- 


188  GUNSHOT    WOUNDS 

stroyed  it  is  preferable  to  defer  enucleation  until  after  closure  of  the 
wound  in  the  orbital  roof.  In  cases  of  lodged  balls  in  and  about  the 
orbit  the  missile  should  be  removed  at  once  and  enucleation  practised 


Fig.  114. — Pvt.  Cornelius  L.  E.  Co.  "K,"  1st  Neb.  Vol.  shot  in  face  by  a  45.  cal.  brass-jacketed 
Remington  bullet  Feb.  5,  1899  at  Block-house  No.  7,  P.  I.  Bullet  entered  over  left  eye-brow  1/2 
inch  from  inner  canthus  and  lodged  in  right  antrum  of  Highmore.  Removed  by  Maj.  A.  C.  Girard, 
M.  C,  U.  S.  A.,  at  Lettermann  Genl.  Hospital,  Aug.  16,  1899.  Remote  effects:  Partial  deafness 
left  ear:  total  blindness  right  eye  from  choroiditis  and  optic  atrophy.  Anchylosis  of  jaw,  but  slight 
separation    of   teeth.     Lettermann    Hospital    X-ray  Laboratory. 

at  the  time  if  necessaiy.  Fracture  of  the  upper  jaw  seldom  needs 
active  treatment  except  to  remove  spiculse  of  bone,  teeth,  and  lodged 
missiles  when   localized  by  the  X-ray  or  otherwise.     In  the  case  of 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK 


189 


the  mandible  when  the  buccal  cavity  is  involved,  prompt  active 
treatment  is  necessary  to  remove  all  pieces  of  loose  bone  which  may 
favor  suppm-ation  and  necrosis  later.  Prompt  removal  of  com- 
minuted bone  should  also  be  practised  in  fractures  of  the  ramus  to 
forestall  anchylosis  of  the  lower  jaw,  which  is  so  apt  to  occur  Tvdth  the 
extensive  comminution  and  resulting  callus.  Fixation  should  be 
practised  by  a  four-tailed  chin  bandage  which  is  about  all  that  is 
obtainable   in  the  field.     Later   the   more   permanent  and  effective 


Fig.  115. — This  soldier  shot  himself  at  Jolo,  P.  I.,  in  1907,  with  Springfield  rifle  cal.  .30  more  by- 
accident  than  intent.  While  in  the  company  of  several  of  his  comrades  one  evening,  he  desired  them 
to  believe  that  he  was  about  to  commit  suicide  and  placed  the  muzzle  of  his  weapon  under  his  chin 
saying,  "here  goes  boys,"  at  the  same  time  pulling  the  trigger.  He  admitted  afterward  that  he 
intended  to  throw  his  head  back  far  enough  to  avoid  the  ball,  but  failed  to  do  so,  receiving  a  wound 
which  shattered  the  inferior  maxillary  bone  and  lacerated  the  surrounding  tissues.  The  case  illus- 
trates how  much  disfigurement  can  occur  from  reduced  caliber  rifle  bullets  at  proximal  ranges. 
Army  Medical  School  collection. 


methods  of  fixation  should  be  employed.  Wounds  of  the  lips,  cheeks, 
and  tongue  usually  heal  rapidly.  Antiseptic  mouth  washes  should 
be  emploj'ed  in  wounds  implicating  the  tongue,  buccal  and  nasal 
cavities. 

(3)  Gunshot  Wounds  of  the  Neck. — Shot  wounds  of  the  neck 
exclusive  of  injury  to  cervical  vertebrge  are  not  excessively  fatal.  Of 
4114  known  results  of  this  class  of  cases  reported  in  the  surgical  vol- 


190 


GUNSHOT   WOUNDS 


umes  of  the  Civil  War,  Otis  gives  a  mortality  of  15  per  cent.  The 
sub-joined  table^  from  the  same  source,  aside  from  giving  the  mortality 
for  that  time,  is  interesting  as  it  gives  the  ratio  of  hits  in  some  of  the 
important  anatomical  structures  for  a  large  number  of  neck  wounds. 

TABLE  OF  4895  CASES  OF  GUNSHOT  WOUNDS  OF  THE  NECK  WITHOUT  KNOWN 
INJURY  TO  THE  CERVICAL  VERTEBRiE  (OTIS) 


Character  of  wound 


Cases 

Died 

Dis- 
charged 

4789 

570 

1056 

41 

21 

11 

30 

10 

8 

13 

7 

2 

10 

6 

2 

4 

1 

Duty 


Un- 
known 


Gunshot  Wounds  of  the  Neck 

Gunshot  Wounds  of  the  Neck,  injuring  Trachea 

Gunshot  Wounds  of  the  Neck,  injuring  Larynx 

Gunshot  Wounds  of  the  Neck;  injuring  Pharynx 

Gunshot  Wounds  of  the  Neck,  injuring  Esophagus 

Gunshot  Wounds  of  the  Neck,  injuring  Tra.  &  Lar.  .  .  . 
Gunshot  Wounds  of  the  Neck,  injuring  Tra.  &  Phar. .  . 
Gunshot  Wounds  of  the  Neck,  injuring  Tra.  &  Esoph.  . 
Gunshot  Wounds  of  the  Neck,  injuring  Lar.  &  Esoph.  . 
Gunshot  Wounds  of  the  Neck,  injuring  Phar.  &  Esoph. 
Gunshot  Wounds  of  the  Neck,  injuring  Phar.  &  Lary.  . 


2394 
8 
2 
3 
2 
3 


769 

1 

10 

1 


Aggregates 4895 


1083 


781 


The  high  mortality  in  those  wounds  involving  the  trachea,  larynx, 
pharynx  and  esophagus  alone  or  otherwise  is  no  doubt  significant  of 
the  effects  of  the  armament  and  mode  of  treatment  at  that  time. 
The  large  number  of  cases,  viz.,  4789  of  gunshot  wounds  of  the  neck, 
with  an  aggregate  mortality  of  14.1,  shows  even  for  the  old  armament 
how  curiously  the  large  vessels  and  spinal  cord  escape  injury  in  this 
rather  limited  target  area.  A  line  drawn  transversely  at  the  root  of 
the  average  size  neck  in  life  measures  about  4  1/2  inches,  and  4  inches 
when  the  measurement  is  taken  transversely  across  the  neck  under 
the  extended  chin.  The  antero-posterior  and  oblique  diameters  at 
about  the  same  levels  exceed  these  measurements  by  about  1/2  inch. 
In  the  middle  of  this  space  the  spinal  column  runs  longituchnally 
and  it  measures  on  the  skeleton  approximately  an  average  of  2  inches 
transversely,  while  the  spinal  canal  proper  measures  about  3/4  inch 
in  its  antero-posterior  diameter. 

The  failure  to  note  vertebral  lesions  in  this  array  of  neck  wounds 
is  due  no  doubt  to  their  entire  absence.  Such  cases  were  very  probably 
numbered  among  the  dead  from  direct  injury  to  the  cord  or  as  a  result 
of  vibratory  concussion  in  bone  injuries  so  near  the  vital  centers. 
The  record  makes  note  of  primary  and  secondary  hemorrhage  in  a 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  191 

certain  proportion  of  case.-,  but  the  principal  feature  of  the  neck  wound 
for  that  day  was  the  striking  manner  in  which  the  missiles,  Hke  round 
and  conoidal  lead  balls,  eluded  the  great  vessels  while  from  every 
external  appearance  they  traversed  their  course.  It  was  then  believed, 
and  very  properly,  that  the  vessels  lying  loose  and  movable  in  the 
tissues  were  pushed  aside  by  the  slowly  moving  obtuse  bodies.  In 
those  cases  where  the  vessels  were  severed,  the  larger  caliber  of  those 
days  caused  so  much  laceration  of  the  large  vessels  that  the  result  was 
immediate  death  from  primary  hemorrhage. 

The  beneficence  which  comes  from  reduction  in  the  caliber  of  the 
military  rifle  is  ver}^  evident  from  the  results  in  neck  wounds  in  recent 
wars.  This  was  noticeable  to  us  at  Santiago  in  cases  of  injury  to  the 
air  passages  and  the  great  vessels  ahke.  The  larynx,  trachea,  and 
great  vessels  were  all  in  turn  perforated  without  fatal  outcome.  The 
death  rate  of  133  neck  cases  who  lived  to  reach  hospital  care  in  the 
Spanish- American  War  was  18  per  cent.  Two  of  the  fatal  cases 
were  operated  upon  for  subclavian  aneurj'sm.  Although  the  offi- 
cial reports  from  the  Anglo-Boer  and  Russo-Japanese  Wars  are  not 
yet  available,  we  have  reason  to  beheve  from  the  pubhshed  reports 
of  the  observers  in  these  wars  that  the  results  in  the  Spanish  American 
War  are  a  fair  index  of  the  mortality  to  be  expected  from  shot  wounds 
of  the  neck  under  present  conditions. 

We  noticed  a  number  of  cases,  after  the  battle  of  Santiago,  of 
incredible  escape  of  important  structures  in  the  neck  and  our  observa- 
tions have  been  confirmed  repeatedly  by  observers  in  recent  wars. 

In  the  case  of  Pvt.  0.  C.  Buck,  Co.  F,  2nd  Infantry,  who  was 
shot  by  a  sharp-shooter  July  11,  ?  Spanish  Mauser  bullet  passed 
transversely  through  the  neck.  Profuse  bleeding  from  the  throat 
followed  immediately,  but  this  soon  subsided  and  ceased  entirely 
during  the  day.  No  other  symptoms  were  present  in  the  subsequent 
history  of  the  case  except  shght  stiffness  of  the  neck  and  pain  on 
movement.  The  bullet  entered  on  the  left  side  2  inches  below  the 
mastoid  process,  making  a  small  circular  wound,  and  passed  through 
the  sterno-cleido-mastoid  muscle;  the  wound  of  exit  was  on  the  oppo- 
site side  of  the  neck,  on  the  same  level  and  1/2  inch  nearer  the  spine. 
There  were  no  symptoms  of  a  subsequent  nature  referable  to  the 
principal  nerves  and  large  vessels  of  the  neck,  and  yet  it  is  difficult 
to  conceive  how  the  projectile  made  its  passage  through  the  neck 
without  involving  these  important  structures. 

The  spinal  column  and  cord  made  a  marvelous  escape  in  the  case 


192  GUNSHOT   WOUNDS 

of  Pvt.  Charles  F.  F.,  Company  C,  4th  Infantry,  who  was  wounded 
July  1,  while  firing  in  the  prone  position.  The  bullet,  a  Spanish 
Mauser,  entered  the  left  side  of  the  neck  opposite  the  fifth  cervical 
spine  mid-way  between  it  and  the  posterior  border  of  the  sterno- 
cleido-mastoid.  Ranging  downward  and  to  the  right  it  made  its 
exit  opposite  the  seventh  dorsal  spine  half-way  between  it  and  the 
vertebral  border  of  the  scapula.  The  only  symptom  complained  of 
was  pain  in  the  shoulders  on  moving  the  arms.  No  symptoms  of  a 
paralytic  or  other  nature  referable  to  cord  lesion  were  ever  present, 
although  he  was  shot  when  100  yards  from  the  enemy. 

Makins  mentions  the  occurrence  of  "several  cases  in  which  the 
bullet  traversed  the  neck  behind  the  pharynx  and  esophagus  without 
injury  to  either  viscus,  and  the  escape  of  the  main  vessels  and  nerves 
was  equally  striking."  Follenfant  in  Manchuria  states  that  his  com- 
rade. Prince  Murat,  received  a  wound  across  the  neck  which  disabled 
him  very  much  for  six  days.  He  was  back  on  the  line  at  the  end  of 
a  few  weeks.  The  jacketed  bullet  entered  the  right  side  of  the  neck 
under  the  angle  of  the  lower  jaw  and  emerged  on  the  left  side  behind 
the  larynx.  There  was  difficulty  in  deglutition  for  five  days.  No 
after-effects  were  present  save  an  anesthetic  patch  the  size  of  a  5-franc 
piece  on  the  right  side  of  the  neck. 

Complications  of  Gunshot  Wounds  of  the  Neck. — Wounds  of  the 
larynx  and  trachea  are  sometimes  complicated  with  septic  pneumonia ; 
injury  to  the  great  vessels  may  cause  hemorrhage  or  traumatic 
aneurysm,  while  wounds  of  the  esophagus  are  prone  to  infection. 
Infection  in  any  wound  of  the  neck,  unless  carefully  managed,  is  apt 
to  lead  to  deep-seated  inflammation  with  suppuration. 

Wounds  of  the  Great  Vessels  or  Their  Branches. — Aneurysm 
which  arises  from  wounds  of  neck  vessels  will  be  referred  to  under 
"Injury  to  Blood-vessels," 

Hemorrhage  attending  laceration  of  vessels  of  the  neck  when 
alarming  and  continuous  should  be  treated  by  hgation  of  the  vessel 
above  and  below  the  point  of  injury.  In  large  wounds  as  by  shell 
fragments  or  large  lead  bullets,  patients  seldom  live  long  enough 
to  reach  surgical  aid.  Smaller  missiles  like  the  steel-clad  bullets  of  the 
present-day  military  rifle  often  cause  wounds  in  which  the  flow  of 
blood  is  not  constant  both  from  the  small  channel  made  by  the  pro- 
jectile, and  from  obstruction  of  the  flow  which  results  from  a  change 
in  the  position  of  the  overlying  layers  of  muscle,  fascia,  etc.  A  re- 
currence of  the  hemorrhage  after  a  temporary  spurt  of  blood  should 


GUNSHOT   WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  193 

be  an  indication  for  cutting  down  upon  the  bleeding  vessel.  The 
sooner  this  is  done,  the  better  will  be  the  prognosis.  Temporizing  in 
such  cases  leads  to  the  disturbance  of  anatomical  relations  from  the 
distention  which  attends  the  formation  of  diffuse  aneurysm.  In 
our  Civil  War  the  surgeons  were  wont  to  use  pressure  and  styptics. 
Again,  instead  of  cutting  down  upon  the  vessels  at  the  point  of  injury 
they  often  resorted  to  the  faulty  practice  of  tying  the  common  carotid 
to  control  hemorrhage  from  some  of  its  branches.  Otis'  characteri- 
zation of  this  method  is  as  applicable  to-day  as  it  was  then.  To  him 
these  surgeons  were  only  "associating  their  names  with  the  necrology 
of  hgations."  He  makes  note  of  a  total  of  seventy-six  hgations  of 
the  common  carotid  for  gunshot  about  the  face  and  neck  with  a  mor- 
tality of  78.6  per  cent.  This  practice  was  not  attended  with  very 
much  better  results  in  the  Franco-Russian  War  of  1870-71,  where  the 
registered  mortalitj''  in  like  cases  was  68.7,  in  the  German  Army. 
The  surgical  practice  of  to-day  is  to  cut  down  and  tie  the  bleeding 
points  in  the  wound  wherever  this  is  possible.  When,  however,  the 
wound  in  the  neck  is  above  the  bifurcation  of  the  common  carotid, 
in  the  parotid  region,  there  is  usually  much  difficulty  in  attempting 
to  expose  the  bleeding  vessel.  It  is  then  difficult  to  ascertain  which 
of  the  divisions  of  the  main  trunk  is  causing  the  hemorrhage.  In 
such  a  case  operators  follow  the  practice  first  recommended  by  Richet 
of  exposing  the  origin  of  the  two  carotids,  then  successively  to  compress 
the  vessels  and  finally  to  tie  the  one  that  seems  to  control  the  hemor- 
rhage. If  the  compression  of  the  one  or  the  other  does  not  entirely 
arrest  the  hemorrhage,  he  then  advises  ligation  of  both  the  external 
and  internal  carotids.  As  an  additional  precautionary  measure  to 
prevent  a  recurrence  of  the  hemorrhage,  Delorme^  would  enlarge  the 
skin  incision  and  pack  the  wound  with  antiseptic  tampons.  Follen- 
fant^  states  that  Bornhaupt,  contrary  to  the  usual  practice,  tied  the 
common  carotid  twice  successfully  for  hemorrhage  in  the  late  Russo- 
Japanese  War. 

Wounds  of  the  Jugular  Veins. — Wounds  of  the  external  jugular 
is  of  no  moment  in  our  day,  though  Otis  records  some  cases  of  death 
from  gunshot  of  this  vessel  in  our  great  Civil  War.  Ligation  of  both 
ends  of  the  vessel  under  proper  antiseptic  precautions  is  the  treatment 
now  employed.  Wounds  of  the  internal  jugular  have  a  high  mor- 
tality.    Large  veins  are  not  as  resistant  as  the  large  arteries,  they  are 

1  Delorme  E,  Traite  de  Chirurgie  de  Guerre. 
-  Op.  cit. 


194  GUNSHOT    WOUNDS 

not  pushed  aside  as  readih^  by  slowly  moving  projectiles  and  it  is  more 
than  likely  that  the  mortalitj^  on  the  field  from  primary  hemorrhage 
is  frequent  from  uncontrolable  venous  hemorrhage.  Otis  records 
fifteen  cases  of  wounds  to  the  internal  jugular  with  fourteen  deaths. 
Eight  of  the  deaths  are  ascribed  to  hemorrhage,  five  not  stated,  and 
one  from  typhoid  pneumonia.  Of  the  cases  of  gunshot  wound  of  the 
internal  jugular  collected  by  Gross  the  fatality  was  12.5  per  cent, 
from  primary  hemorrhage;  62.5  per  cent,  from  secondary  hemorrhage; 
25  per  cent,  from  pj^emia.  These  statistics  are  of  much  value  since 
they  point  to  causes  of  death  in  87.5  per  cent,  of  the  cases,  which 
under  modern  methods  of  treatment  are  largely  preventable.  Doubt- 
less the  mortality  of  12.5  per  cent,  from  primary  hemorrhage  could 
be  much  reduced  by  ligation  of  the  vein,  which  is  now  clone  with 
perfect  safety.  Injury  to  the  jugulars  and  other  large  veins  by  the 
modern  rifle  bullet,  which  are  accessible  to  operative  interference 
when  seen  in  time,  will  be  especially  amenable  to  surgical  relief  in 
the  majority  of  cases.  Where  the  vein  has  been  hit  at  a  tangent, 
application  of  fine  sutures  to  the  margins  of  the  wound  in  the  vessel 
is  one  of  the  recognized  procedures.  If  the  wound  is  very  small  it 
can  be  brought  together  bj^  a  hemostat  which  can  be  left  in  situ  for 
a  few  days.  Where  the  vessel  has  been  perforated  by  the  projectile, 
destroying  the  greater  part  of  its  lumen,  the  procedure  is  the  same  as 
that  followed  in  the  case  of  an  injured  artery,  viz.,  hgation  of  the  vessel 
above  and  below  the  point  of  injurj'. 

Wounds  of  the  Nerves  of  the  Neck. — All  the  nerves  of  the  neck 
including  the  sympathetic  are  subject  to  injury  by  gunshot.  Unlike 
injur}^  to  nerves  of  other  regions  there  is  little  that  can  be  done  in 
the  way  of  surgical  relief  for  nerve  injuries  in  this  locality. 

The  German  reports  for  the  war  of  1870-71  places  the  frequency 
of  nerve  injuries  as  1  to  12  of  all  neck  wounds  by  gunshots.  These 
injuries  are  often  followed  bj'  interesting  clinical  signs.  Injury  to  the 
seventh  nerve,  which  often  occurs  in  wounds  about  the  parotid,  is 
invariably  followed  by  complete  or  partial  facial  paralysis.  Wound  of 
the  recurrent  laryngeal  will  cause  paralysis  of  the  muscles  of  phonation 
on  the  corresponding  side  with  difficulty  in  speech;  lesion  of  the 
spinal  accessory  by  paralysis  of  the  mastoid  and  trapezius  muscles;  of 
the  phrenic  by  paralysis  of  the  diaphragm  on  the  corresponding  side, 
with  hiccough,  dyspnea  and  a  sensation  of  constriction  around  the 
body.  Of  the  foregoing  injuries  wounds  of  the  phrenic  are  the  most 
serious. 


GUNSHOT    WOUNDS    OF    THE    HEAD,    FACE    AND    NECK  195 

Wounds  of  the  pneumogastric  by  gunshot  are  attended  with 
an  interesting  and  curious  cHnical  history.  By  reason  of  the  nerve's 
intimate  relation  to  the  large  vessels  the  latter  are  nearly  always  im- 
plicated, but  in  some  rare  instances  the  nerve  alone  has  been  injured, 
and  the  sj^mptoms  of  injurj^  to  it  have  also  been  noted  where  the 
primarj^  hemorrhage  of  the  vessels  has  been  successfully  arrested. 
The  pneumogastric  is  often  implicated  in  neck  injuries,  by  (a)  direct 
traumatism,  (b)  by  pressure  in  cases  of  aneurysm  and  (c)  by  the  vibra- 
tory force  of  high-power  militarj^  rifles  of  the  present  day.  Injury  to 
this  important  nerve  is  followed  by  difficulties  of  deglutition,  phonation 
and  respiration;  irregularity  and  acceleration  of  the  heart  beats,  and 
later  by  pneumonia  which  is  sometimes  a  cause  of  death.  Makins  states 
that  the  pneumogastric  was  often  implicated  in  gunshot  wounds  of  the 
neck  in  the  South  African  War.  He  never  observed  an  uncomplicated 
case.  He  is  of  the  opinion  that  injury  to  the  pneumogastric  was  a  fre- 
quent cause  of  death  on  the  field  among  those  hit  in  the  neck.  The 
staff  of  A  Civilian  War  Hospital  reports  a  case  as  follows:  "A  private 
was  shot  through  the  right  orbit  at  Magersfontein,  the  bullet  traversing 
the  jaw-bone  and  palate,  and  emerging  through  the  left  side  of  the 
neck  just  at  the  back  of  the  thj^roid  cartilage.  There  was  a  complete 
paralysis  of  the  vocal  cord,  followed  by  atrophy  of  the  muscles,  which 
could  onty  have  been  caused  by  a  wound  of  the  pneumogastric  nerve, 
but  the  patient  had  no  other  symptoms  which  could  be  attributed  to 
such  an  injury,  and  made  a  good  recovery." 

Wounds  of  the  neck  high  up  are  apt  to  involve  the  h3^poglossal  as 
well  as  the  pneumogastric.  Hirsch^  reports  a  case  in  which  the  ball 
lodged  opposite  the  fourth  cervical  vertebra  as  shown  by  the  skiagram. 
The  hypoglossal  involvement  was  shown  by  atrophy  of  one-half  of 
the  tongue,  and  the  pneumogastric  injury  caused  paralysis  of  the  left 
vocal  cord  and  a  continued  high  pulse,  108. 

The  pressure  symptoms  of  vagus  involvement  will  be  more  frequent 
with  the  use  of  the  new  military  rifle,  since  aneurysm  is  now  more 
often  noted  after  wounds  of  the  vessels  by  the  small-caliber  bullet. 

Roswell  Park  and  Makins-  have  shown  that  the  vagus  can  be  cut  in 
operative  wounds,  and  immediately  sutured,  with  incomplete  tem- 
porary loss  of  function. 

Wounds  of  the  Cervical  Sympathetic. — From  the  intimate  anatomi- 

1  Hirsch,  Traumatic  Injury  of  the  Pneumogastric  Nerve,  etc.,  N.  Y.  Med.  J., 
Vol.  LXVI. 

2 London  Lancet,  May  16,  1896. 


196  GUNSHOT   WOUNDS 

cal  relation  of  the  cervical  sympathetic  to  the  great  vessels,  the  pneumo- 
gastric,  the  cord,  air  passages,  and  esophagus,  uncomplicated  injury  to 
the  nerve  is  seldom  seen.  In  those  cases  of  vessel  injury  in  which  recov- 
ery has  taken  place,  the  characteristic  symptoms  of  cervical  sympa- 
thetic injury  have  been  noted.  The  symptoms  which  appear  only  upon 
complete  division  of  the  nerve  are  as  follows:  (a)  Narrowing  of  the 
palpebral  fissure,  (b)  sinking  in  of  the  eye-ball,  (c)  contracted  pupil, 
(d)  loss  of  the  cilio-spinal  reflex,  (e)  redness  and  dryness  of  the  skin 
of  the  corresponding  side  of  the  face.  In  partial  injury  to  the  nerve 
only  some  of  the  foregoing  symptoms  appear.  Reddening  of  the  cheek 
is  one  of  the  symptoms  rarely  seen.  Excessive  flow  of  tears  sometimes 
occurs  and  it  generally  proves  to  be  the  most  annoying  symptom.  In 
a  certain  proportion  of  cases  the  symptoms  are  permanent.  Larrey 
and  Weir  Mitchell  have  reported  very  interesting  cases  of  wounds  of 
the  cervical  sympathetic  in  war.  Stevenson  states  that  Col.  Holt  has 
reported  several  cases  from  the  Boer  War,  in  which  the  three  most 
prominent  symptoms  were  "increase  of  the  sweating,  myosis,  and 
pseudoptosis  (narrowing  of  the  palpebral  fissures)  on  the  side  of  the 
injury."  Holt  adds  that  "marked  cardiac  rhythmic  disturbance  and 
subconjunctival  hemorrhage  were  ascribed  to  injury  of  this  nerve." 

The  staff  of  A  Civilian  War  Hospital  notes  the  following  case  in 
the  same  war :  "A  private  was  shot  through  the  right  side  of  the  neck, 
the  bullet  entering  at  the  middle  of  the  left  cheek,  and  pass  ng  out  1  1/2 
inches  to  the  right  of  the  spinous  process  of  the  seventh  cervical  vertebra. 
The  left  eye-ball  showed  the  typical  retraction  of  the  globe  within  the 
orbit,  the  diminished  palpebral  fissure,  and  the  paralysis  of  the  dilator 
muscle  of  the  iris  characteristic  of  paralysis  of  the  sympathetic  nerve." 

Wounds  of  the  Brachial  Plexus. — These  are  among  the  more 
common  nerve  injuries  of  the  neck.  They  are  often  followed  by  an- 
noying symptoms  of  irritation  in  the  way  of  hyperesthesia  or  pain. 
The  following  case  of  brachial  nerve  injury  occurred  at  the  battle  of 
Santiago.  The  injury  is  typical  of  the  hairbreadth  escapes  which 
we  sometimes  observe  with  the  use  of  the  new  armament. 

Captain  C.  W.  T.,  9th  U.  S.  Cavalry,  was  shot  during  a  plunging 
fire  July  2,  at  about  300  yards,  while  locating  the  enemy  and  estimat- 
ing the  range  for  his  men  who  were  lying  down.  The  bullet,  a  Mauser, 
entered  the  left  side  of  the  neck  on  about  the  level  of  the  upper  border 
of  the  thyroid  cartilage  and  just  internal  to  the  sterno-cleido-mastoid. 
The  bullet's  course  was  downward,  backward  and  obliquely  to  the 
right,  making  its  escape  from  the  body  1  inch  to  the  right  of  the  spine 


GUNSHOT   WOUNDS    OF   THE    HEAD,    FACE    AND    NECK 


197 


of  the  seventh  cervical  vertebra.  He  fell  heavily  to  the  ground  and 
a  sergeant  who  was  near  thought  him  dead.  He  remained  uncon- 
scious for  a  few  minutes  only.  He  was  admitted  to  the  Reserve 
Divisional  Hospital  on  the  third  of  July,  complaining  of  pain  in  the 
distribution  of  the  left  median  nerve ;  the  neck  and  left  arm  were  swol- 
len and  stiff.  The  author  again  examined  this  officer  in  December, 
and  off  and  on  for  four  years  thereafter.  He  was  never  free  from 
hyperesthesia,  formication,  numbness,  and  neuralgic  pains  of  the  left 
arm  and  hand.  The  grip  of  the  left  hand  was  about  half  the  power 
of  the  right.  Judging  from  the  course  of  the  bullet  and  the  persist- 
ency with  which  the  symptoms  of 
irritation  continued,  the  projectile 
more  than  likely  perforated  the 
transverse  processes  of  the  fifth 
and  sixth  cervical  vertebrae,  injur- 
ing the  corresponding  cervical 
nerves,  and  passing  between  the 
spines  of  the  sixth  and  seventh 
vertebrae  it  emerged  an  inch  to  the 
right  of  the  latter.  The  force  of 
impact  which  caused  the  officer  to 
drop  so  lifeless  when  shot  would  in- 
dicate that  the  spinal  cord  had  re- 
ceived a  momentary  shock  from 
the  transmission  of  the  bullet's 
energy  at  high  velocity.  (Fig. 
116.) 

Wounds  of  the  Air  Passages. — 
Wounds  of  the  larynx  and  trachea        fig.  ii 6.— Photograph  of  cadaver  show- 
by    the    old    armament    were  not  '""^  '=°"'"^'^  °^  ^"^"^^  ^"^  "'^"^  °^  ^'"p*-  ^-  ^-  '^•' 

•^  ....  ,  9th  U.  S.  Cavalry. 

commonly  seen  m  military  hos- 
pitals. The  proximity  of  the  great  vessels  and  spinal  cord  made  it 
difficult  for  a  bullet  of  large  cahber  to  traverse  the  air  passages  with- 
out causing  injury  of  a  fatal  kind  to  either  the  vessels,  the  cord  or 
both.  Chenu  gives  but  one  example  of  cure  from  gunshot  of  the 
larynx  in  the  Crimean  War,  and  that  was  complicated  by  a  fistule. 
Otis'  table  referred  to  shows  that  the  air  passages  of  the  neck  were  in- 
cluded in  but  seventy-seven  of  4895  gunshot  wounds,  or  1.7  per  cent. 
for  all  neck  wounds  treated.  The  mortality  of  tracheal  and  laryngeal 
wounds  treated  was  practically  the  same — 50  per  cent. 


198  GUNSHOT   WOUNDS 

Wounds  of  the  larynx  and  trachea  that  reach  hospitals  are  as  a 
rule  disposed  transversely  across  the  neck.  Perforating  shots  of  the 
neck  from  large  calibers  directed  antero-posteriorly  or  those  travers- 
ing the  neck  behind  the  air  passages  are  very  likely  to  injure  the  great 
vessels  or  cord  with  fatal  results.  Oblique,  antero-posterior,  or  postero- 
anterior  shots  with  low  velocity,  effecting  lodgment,  are  mentioned 
by  Otis  and  others  as  capable  of  injury  to  the  laryngo-tracheal  tube 
without  fatal  issue.  The  prominence  of  the  larynx  and  trachea  leaves 
them  exposed  to  all  transverse  shots  across  the  neck  anterior  to  the 
vessels  and  it  was  to  this  class  that  the  hospital  cases  belonged  formerly. 

The  beneficence  which  has  come  from  a  reduction  of  caliber  is 
particularly  shown  in  neck  wounds  including  the  laryngo-tracheal 
tube.  Military  surgeons  in  recent  wars  have  repeatedly  referred  to 
the  rapid  recovery  of  uncomplicated  larynx  and  tracheal  wounds  by 
reduced-caliber  bullets.  Follenfant^  reports  thirty-three  cases  in  the 
Manchurian  campaign  with  three  deaths.  Ten  cases  were  discharged 
cured  and  nineteen  were  transferred. 

Oettingen,^  who  commanded  a  Red  Cross  hospital  on  the  Russian 
side  in  the  same  campaign,  states  that  the  number  of  tracheal  wounds 
was  small,  that  none  proved  dangerous.  In  those  cases  where  large 
vessels  were  involved  or  in  cases  from  shrapnel  or  large  missiles  trache- 
otomy was  indicated,  otherwise  the  treatment  was  expectant. 

Hemorrhage  and  asphyxia  are  the  immediate  dangers  to  life  which 
present  themselves  in  wounds  of  the  air  passages.  The  hemorrhage 
arises  from  the  neck  vessels  when  they  are  injured,  and  asphyxia  re- 
sults from  the  escape  of  blood  into  the  smaller  bronchioles  and  air  cells 
of  the  lungs.  Later,  pneumonia  and  edema  glottidis  sometimes  arise. 
As  a  sequel  stricture  of  the  larynx  or  trachea  occurs  in  a  certain 
proportion  of  cases.  Pvt.  Jacob  H.  Mose,  Co.  A,  4th  U.  S.  Infantry, 
was  shot  by  a  Mauser  bullet  before  Santiago,  July  2,  while  he  was 
lying  clown.  "The  bullet  entered  right  temple  2  1/2  inches  above  and 
1  inch  posterior  to  the  right  canthus.  It  passed  through  the  superior 
maxilla  downward  and  backward,  cut^  through  the  posterior  portion 
of  the  soft  palate  and  entered  the  neck.  Here  it  became  deflected, 
probably  by  the  thyroid  bone,  and  entered  the  thyroid  cartilage, 
thoroughly  comminuting  it,  cutting  into  the  esophagus  wall  where, 
being  spent,  it  dropped  into  the  stomach."     The  patient  states  that 

1  M.  FoUenfant,  Arch,  de  Medecine  et  de  Phar.  Mil.,  No.  48,  p.  84,  1906. 

2  Walter  von  Oettingen,  Studien  auf  dem  Gebiete  des  Kriegs  Sanitats  Wesesn 
im  Russisch-Japanischem  Kriege,  1904-1905.     BerUn,  1907.   ■ 

3  Dr.  Emil  Meyer,  Meeting  A.  M.  Association,  1900. 


GUNSHOT   WOUNDS    OF   THE    HEAD,    FACE    AND    NECK 


199 


he  subsequently  passed  the  bullet  per  rectum.  There  was  profuse 
hemorrhage  from  the  mouth  and  nose.  He  experienced  difficulty  in 
breathing  and  swallowing.  The  difficulty  in  breathing  became  so  ag- 
gravated that  it  was  necessary  to  perform  tracheotomy  August  3. 
He  is  still  wearing  the  tracheotomy  tube.  There  is  complete  obstruc- 
tion in  the  larynx.  His  voice  is  heard  in  a  whisper  when  the  finger  is 
pressed  over  the  tracheotomy  tube.  The  laryngoscopic  appearances 
are  described  in  Dr.  Meyer's  article. 

Treatment. — Wounds  of  the  larynx 
and  trachea  need  prompt  attention  on 
surgical  lines.  Wounds  of  the  front 
segment  of  the  trachea  without  undue 
loss  of  substance  are  best  treated  by 
suturing  if  the  respiratory  efforts  will 
permit.  Tracheotomy  is  in  order  in 
all  cases  where  dyspnea  is  present. 
Bleeding  from  injured  vessels  should 
be  arrested  by  ligation  and  when  the 
esophagus  is  wounded,  if  there  is  much 
difficulty  in  swallowing  with  extravasa- 
tion of  food  in  the  tissues  of  the  neck, 
feeding  should  be  done  through  an 
esophageal  tube  introduced  into  the 
stomach  through  the  mouth  or  a  small 
flexible  catheter  maybe  passed  through 
the  nose  into  the  stomach.  When 
ever  the  wound  in  the  esophagus  is 
exposed  and  permits  suturing  this 
should  be  done,  leaving  provision  at  the  bottom  of  the  wound  for 
drainage.  Cellulitis  being  a  frequent  accompaniment  of  neck  wounds, 
provision  for  drainage  is  never  amiss  in  the  application  of  the  primary 
dressing. 


Fig.  117.— Photograph  of  J.  H.  Mose, 
March  4,  1911,  at  which  time  he  was 
still  wearing  tracheotomy  tube. 


CHAPTER  VII 
Gunshot  Wounds  of  the  Spine 

Of  all  cases  of  gunshot  wounds  that  live  to  receive  hospital  care, 
those  suffering  gunshot  fracture  of  the  spine  are  the  most  fatal,  not 
excepting  gunshot  fractures  of  the  calvarium. 

Out  of  642  gunshot  fractures  of  the  spine  during  the  Civil  War, 
in  his  concluding  observations,  Otis  places  the  mortality  in  the  aggre- 
gate at  55.5  per  cent.  He  shows  that  the  fatality  increases  as  the 
seat  of  injury  approaches  the  head  as  follows: 

Cervical  spine 70      per  cent. 

Dorsal  spine 6-3      per  cent. 

Lumbar  spine 45 . 5  per  cent. 

In  the  German  reports  for  the  Franco-German  War,  1870-71, 
the  fatality  on  the  contrary  diminishes  with  proximity  of  the  injury 
to  the  head  as  follows: 

Cervical  spine 61.3  per  cent. 

Dorsal  spine 70. 9  per  cent. 

Lumbar  spine 71.9  per  cent. 

These  figures  fairly  represent  the  mortality  for  the  preantiseptic 
era  when  the  large  low-velocity  projectiles  were  in  use.  Although 
we  have  not  yet  received  authentic  figures  of  the  mortality  in  spinal 
fractures  for  the  great  war  in  Manchuria,  we  have  enough  evidence 
from  the  Spanish-American  and  Anglo-Boer  Wars  to  show  that  the 
use  of  antisepsis,  and  the  employment  of  the  so-called  humane  small- 
caliber  bullet,  have  given  us  little  if  any  encouragement  looking  to 
the  reduction  of  the  old-time  mortality  in  gunshot  fractures  of  the 
spine.  The  results  in  thirty-six  cases  gathered  from  the  Spanish- 
American  War  and  Philippine  Insurrection,  the  majority  having 
resulted  from  gunshot  by  the  reduced-caliber  bullet,  have  given  us  a 
mortality  of  75  per  cent,  for  the  spine  as  a  whole.  For  the  Anglo- 
Boer  War  Stevenson  reports  the  mortality  in  forty-eight  gunshot 
injuries  of  the  spine  as  follows: 

Cervical  spine  (5  cases) 60      per  cent. 

Dorsal  spine  (41  cases) 60 . 9  per  cent. 

Lumbar  spine  (2  cases) 00      per  cent. 

200        , 


GUNSHOT    WOUNDS    OF    THE    SPINE  201 

He  also  makes  use  of  the  following  very  significant  statement — 
"Fracture  of  the  neural  arch  and  actual  lesion  of  the  cord  by  bone  or 
bullet  in  all  regions  of  the  spine  taken  together  give  a  death  rate  of  a 
little  over  78  per  cent."  This  high  mortality  refers  to  cases  in  which 
the  lesion  was  definitely  ascertained  and  it  corresponds  very  closely 
to  the  mortality  in  the  Spanish- American  War  just  referred  to  in 
which  there  is  a  mortality  of  75  per  cent,  for  a  similar  class  of  cases. 
These  figures  establish  beyond  doubt  that  the  mortality  of  gunshot 
fractures  of  the  spine  has  not  diminished  under  modern  conditions 
and  that  it  is  as  great  to-day  if  not  greater  than  formerly. 

There  is  another  significant  feature  of  gunshot  fractures  of  the 
spine  which  concerns  the  military  surgeon  especially,  and  that  relates 
to  their  greater  frequency  from  the  effects  of  the  new,  as  compared 
to  the  lesions  sustained  by  the  old  armament.  Borden^  points  out 
that  the  frequency  of  the  grave  injuries  of  the  spine  has  been  more  than 
doubled  since  the  introduction  of  high-velocity  jacketed  bullets. 
In  the  Civil  War,  with  the  use  of  the  low-velocity  lead  bullets  the 
relative  frequency  of  spinal  fractures  was  0.26  per  cent.,  while  it  was 
increased  to  0.55  per  cent,  in  the  Spanish-American  War  and  to  0.82 
per  cent,  in  the  Philippine  Insurrection.  With  the  use  of  low  velocities 
in  former  times,  the  spine  received  great  protection  from  its  position 
at  the  back.  The  comparatively  low  energy  of  the  old  conoidal 
bullets,  except  at  proximal  ranges,  was  sufficiently  expended  after 
penetrating  intervening  tissues  in  front  of  the  spine  to  ward  off  fracture 
in  the  majority  of  cases,  and  the  injury  to  the  spine  more  often  resulted 
in  contusion  of  the  bony  structures  or  lodged  balls.  The  protecting 
layers  of  tissue  like  the  abdominal  wall,  abdominal  contents,  the 
thoracic  walls,  thoracic  viscera,  etc.,  are  still  a  protection  against 
spinal  injury  from  low-velocity  projectiles  of  all  kinds,  viz.,  spent 
balls,  shrapnel  and  shell  fragments.  The  protective  layers  mentioned, 
however,  are  as  nothing  to  ward  off  fracture  with  the  use  of  a  small 
jacketed  bullet,  the  caliber  of  a  lead  pencil,  traveling  at  high  velocity. 
Such  a  bullet  except  when  it  is  operating  as  a  spent  ball  is  not  deflected. 
Its  course  is  forward  and  onward  in  a  direct  path.  The  bony  spine 
itself  offers  but  little  hindrance  to  its  penetrating  effects.  When  it 
chances  to  strike  the  body  of  a  vertebra,  which  is  made  up  of  can- 
cellous tissue,  it  makes  a  clean-cut  perforation  with  little  or  no  splin- 
tering.    The  compact  substance  of  the  neural  arches,  the  spines  and 

1  American  Practice  of  Surgery  by  Bryant  and  Buck,  Lt.-Col.  W.  C.  Borden, 
U.  S.  Army. 


202  GUNSHOT   WOUNDS 

transverse  processes  are  splintered  more  often  transversely  as  shown 
by  Delorme^  and  the  amount  of  shattering  is  in  proportion  to  the 
velocity  of  the  missile  and  the  resistance  encountered.  The  bullet 
itself  or  secondarj^  missiles  like  spiculse  of  bone  or  metallic  particles 
from  the  bullet  traverse  the  canal  or  the  immediate  vicinity  of  its 
bony  walls  with  readiness,  inflicting  direct  or  indirect  injury  propor- 
tional to  the  remaining  velocity  of  the  projectile  at  the  time  of  impact. 
Concussion  of  the  Cord  by  Large-caliber  Bullets. — In  former 
times  the  anatomical  lesions  of  the  spinal  cord,  produced  independently 
of  direct  traumatism  by  the  ball  or  fragments  of  bone,  were  appre- 
ciated by  the  surgeons  of  our  Civil  War,  as  pointed  out  by  Otis,  and 
discussed  by  LidelP  of  the  Volunteer  Army.  The  concussion  was 
attributed  to  impact  of  the  bullet  against  the  spine.  The  symptoms 
were  varied,  from  motor  enfeeblement  of  the  lower  extremities  with 
numbness,  and  sensations  of  "pins  and  needles  on  the  one  hand,  to 
complete  paraplegia,  both  motor  and  sensory,  with  priapism  and 
retention  of  urine  and  feces  on  the  other."  Lidell  adds  further  that 
''as  the  symptoms  of  concussion  of  the  brain  result  directly  from 
cerebral  'shocks,'  so  the  symptoms  of  concussion  of  the  spinal  marrow 
result  directljT"  from  sudden  'shock'  of  that  organ."  It  was  then 
believed  that  concussion  of  the  brain  and  cord  were  both  attended  by 
minute  extravasations  of  blood.  It  is  doubtful  if  neurologists  now 
believe  that  extravasation  of  blood  is  a  constant  accompaniment  of 
the  condition  attended  by  temporary  loss  of  consciousness  known  as 
cerebral  concussion.  On  the  other  hand  we  believe  it  is  generally 
admitted  now  that  gross  structural  changes  take  place  in  all  cases  of 
concussion  of  the  cord,  so-called,  and  this  is  usually  shown  by  the 
slow  return  of  function  or  by  the  continuance  of  the  symptoms  in 
all  cases  of  spinal  cord  injury  not  the  result  of  direct  violence. 

Concussion  of  the  Cord  by  Small-caliber  Bullets. — The  anatomical 
lesions  of  the  spinal  cord  independently  of  direct  traumatism  by  the 
ball  or  fragments  of  bone,  and  the  relation  which  the  amount  of 
lesion  bears  to  the  velocity  of  the  reduced-caliber  bullets  at  the  moment 
of  impact,  has  been  specially  pointed  out  by  Mr.  Makins  in  the  Anglo- 
Boer  War.     He  classes  these  lesions  as  follows: 

1.  Slight  concussion. 

2.  Severe  concussion. 

1  Traite  de  chirurgie  de  guerre  by  E.  Delorme,  Paris,  1903. 
-  International  Encyclopedia  of  Surgery,  Ashhurst,    1884,   Vol.   IV,   p.   788. 
By  John  A.  Lidell,  late  Surg,  of  U.  S.  Volunteers. 


GUNSHOT    WOUNDS    OF   THE    SPINE 


203 


3.  Contusion. 

4.  Hemorrhage. 

5.  Intra-medullary  Hemorrhage  (Hemato-myelia). 

He  points  out  that  an}^  of  these  lesions  may  be  caused  by  the  ''vi- 
bratory force  communicated  to  the  cord  by  its  enveloping  bony  canal." 

(1)  Slight  concussion  is  likened  to  the  form  of  spinal  concussion 
noticed  in  civil  practice  from  causes  such  as  railway  collisions.  The 
cases  noted  by  Makins  showed  transient  symptoms,  there  were  no 
deaths  and  no  opportunity  to  note  anatomical  changes. 

(2)  Severe  concussion  results  when  a  bullet  traveling  at  great 
velocity  collides  -^nth  the  spine.  There  is  parenchymatous  hemor- 
rhage in  many  of  the  cases  and, 
reasoning  upon  the  vibratory  force 
that  could  induce  such  a  trauma, 
it  is  assumed  that  there  is  more 
or  less  complete  disorganization  of 
the  cord.  The  condition  produced 
is  allied  to  one  of  contusion  in  which 
a  localized  portion  of  the  spinal  cord 
sustains  a  destructive  process  suffi- 
cient to  "interrupt  the  normal 
channels  of  communication  with 
the  higher  centers."  In  a  number 
of  cases  cited  the  symptoms  are 
those  of  complete  transverse  lesion. 

(3)  Contusion. — Mr.  Makins 
distinguishes  this  condition  from 
pure  concussion  though  the  two 
are  "closely  allied."  In  cases  of 
contusion  the  post-mortem  condi- 
tions showed  adhesion  between  the 
cord  and  enveloping  dura  at  points 
where  the  ball  had  struck  the  neural  arch  without  fracture.  The 
lesion  of  the  cord  which  was  most  marked  suggested  injury  by 
contre-coup.  The  duration  of  life  was  about  five  weeks.  One 
or  two  segments  of  the  cord  were  completely  disorganized,  the 
cord  substance  was  represented  by  a  "  semi-difHuent  yellowish  ma- 
terial of  soft  consistency."  When  held  up  the  membranes  were 
prone  to  collapse  opposite  the  affected  portion  as  shown  in  Fig. 
118.     The  case  to  which  the  figure  refers  is  described  as  follows: 


Fig.  118. — "Appearance  of  spinal  cord 
enclosed  in  membranes  in  case  103  after  re- 
moval from  the  canal.  When  the  mem- 
branes were  opened  a  white  custard-like 
substance  took  place  of  the  cord.  Slight 
evidence  of  extradural  hemorrhage  existed." 
(Makins.) 


204  GUNSHOT    WOUNDS 

"total  transverse  lesion;  slight  intra-clural  hemorrhage.  Wound  of 
entry  (Mauser),  below  spine  of  scapula,  close  to  right  axilla;  exit, 
2  1/2  inches  to  left  of  tenth  dorsal  spinous  process.  Complete  motor 
and  sensory  paralysis  below  ensiform  cartilage,  with  well-marked 
hyperesthetic  zone  around  trunk.  All  reflexes  absent.  Retention  of 
urine.  Incontinence  of  feces.  Bed-sores  in  sacral  region  developed  dur- 
ing the  first  two  days,  and  seventeen  days  later  well -developed  serpigi- 
nous trophic  sores  developed  on  the  outer  side  of  each  leg  and  con- 
tinued to  increase  slowly  until  death.  The  paralysis  remained  of  the 
absolutely  flaccid  variety.  Great  emaciation  occurred,  accompanied 
by  hectic  fever,  the  temperature  ranging  from  normal  to  102.5°. 
During  the  third  week  double  pleurisy  developed. 

At  the  post-mortem  no  bone  injury  could  be  detected.  The  cord 
and  dura  mater  were  adherent  over  an  area  corresponding  from  the  fifth 
to  the  eight  dorsal  vertebrae,  and  opposite  the  seventh  the  cord  was 
soft  and  of  the  consistence  of  butter.  A  small  intradural  hemorrhage 
was  still  evident  below  the  main  lesion,  not  extensive  enough  to  give 
rise  to  serious  compression.  General  adhesions  in  each  pleura. 
Cystitis." 

(4)  Hemorrhage. — This  injury  as  a  result  of  vibratory  impulse 
was  found  in  the  form  of  surface  extravasations  (extra  and  intra- 
dural) but  the  more  frequent  kind  of  hemorrhage  is  discussed  under 
the  next  heading. 

(5)  Intra-meduUary  Hemorrhage  (Hemato-myelia). — This  form 
of  hemorrhage  was  nearly  always  associated  with  the  changes  due  to 
concussion.  Its  frequency  was  not  definitely  ascertained  but  it  was 
more  than  likely  frequent  and  it  is  suggested  that  it  was  an  accom- 
paniment of  nearly  all  grave  transverse  lesions  not  due  to  direct 
injury  like  compression  or  laceration. 

In  all  of  his  experience  in  the  South  African  War  Mr,  Makins 
states  that  he  saw  only  one  case  of  direct  pressure  upon  the  cord  by  a 
bullet  and  "none  in  which  this  was  due  to  displaced  bone  fragments." 
He  states  further  that  the  transverse  lesions  which  were  indicated  by 
the  symptoms  were  in  his  opinion  due  in  nine-tenths  of  the  cases  to 
"the  conditions  of  concussion,  contusion,  or  hemato-myelia."  This 
opinion  based  as  we  believe  on  sound  judgment  and  sufficient  experi- 
ence has  a  great  bearing  on  the  treatment  of  gunshot  of  the  spine  and 
to  us  it  goes  far  to  explain  certain  cases  which  we  saw  during  the 
Spanish-American  War. 

Concussion  of  the  cord  in  this  respect  simulates  concussion  of  the 


GUNSHOT   WOUNDS    OF   THE    SPINE  205 

brain  which  results  from  molecular  vibrations.  In  the  case  of  the 
more  severe  concussions  of  the  cord  from  gunshot  the  lateral  trans- 
mission of  energy  is  so  great  that  there  is  rupture  of  the  cord  sub- 
stance proper  with  parenchymatous  hemorrhage,  and  the  presence  of 
symptoms,  which  mark  a  transverse  lesion,  as  though  the  injury 
had  resulted  from  direct  trauma.  The  macroscopic  lesions  noted 
in  such  cases  arise  from  the  same  force  that  bursts  asunder  the  tins 
filled  with  water  or  semifluid  contents  like  starch-paste,  as  we  have 
shown  in  figures  when  discussing  explosive  effects.  When  impact 
of  the  missile  at  high  velocity  occurs  upon  the  bony  structures  adjacent 
to  the  cord  and  the  cerebrospinal  fluid,  the  bullet's  energy  is  trans- 
mitted by  them  in  the  form  of  a  vibratory  force  with  violence  in  all 
directions,  hence  the  rupture  of  vessels,  disorganization  of  the  paren- 
chyma, and  even  fracture  of  the  cord  itself  in  some  instances. 

Aside  from  the  increased  frequency  of  spinal  lesions  by  the  new 
armament,  on  the  score  of  superior  penetration,  and  direct  violence, 
we  must  credit  Mr.  Makins  for  emphasizing  the  additional  explanation 
of  the  greater  frequency  of  spinal  lesions,  by  the  effects  of  vibratory  force 
also. 

What  is  true  of  the  effects  of  vibratory  force  from  the  projectiles 
of  the  present-day  military  rifle  in  producing  the  various  degrees  of 
concussion  of  the  cord,  is  also  true  of  the  effects  of  vibratory  force 
conveyed  to  the  cord  from  the  larger  and  more  perfect  revolver 
ammunition  of  the  present  day,  and  it  will  become  more  so  still  with 
the  use  of  steel-clad  bullets  now  employed  in  automatic  pistols, 
weapons  which  are  fast  displacing  the  use  of  revolvers  in  civil  life. 
Doctor  Rudolph  Winslow  of  Baltimore  has  recently  written  a  very 
interesting  paper^  with  cases  in  which  he  conclusively  shows  that 
serious  and  even  fatal  lesions  of  the  spinal  cord  may  be  produced  by 
revolver  bullets  as  a  result  of  concussion  without  direct  impact,  and 
he  cites  cases  in  the  experience  of  other  surgeons. 

With  reference  to  the  cases  resulting  from  the  effects  of  the  military 
rifle  the  evidence  cited  by  Mr.  Makins  in  the  South  African  War  is 
most  interesting.  We  had  a  number  of  cases  in  the  Spanish- American 
War  that  could  only  be  explained  on  the  theory  of  spinal  concussion. 
The  following  history  of  First  Lieut.  A.  S.,  13th  Infantry,  was  obtained 
from  the  records  of  the  hospital  ship  Relief:     "  On  July  1,  while  stand- 

^  Complete  Transverse  Destruction  of  the  Spinal  Cord  from  pistol  wound, 
without  penetration  of  the  Spinal  Canal,  by  Rudolph  Winslow,  M.  D.  Trans- 
actions Southern  Surgical  and  Gynecological  Association,  1910. 


206  GUNSHOT    WOUNDS 

ing  with  his  company  at  the  foot  of  a  hill  during  the  advance  on 
Santiago,  received  a  wound  in  the  neck  probably  from  a  Mauser  bullet. 
The  bullet  entered  on  the  right  side  just  below  the  inferior  maxillary 
bone,  1  inch  in  front  of  the  angle  of  the  jaw.  The  wound  of  entrance 
is  a  clean-cut  hole  the  size  of  a  lead  pencil.  The  course  of  the  bullet  was 
backward  and  slightly  downward,  emerging  at  the  back  of  the  neck  on  a 
level  with  and  to  the  left  of  the  fifth  cervical  vertebra.  At  the  time 
of  the  injury  felt  no  pain  at  the  site  of  the  wound  but  says  that  the 
sensation  was  as  if  he  had  been  grasped  by  the  wrists  and  thrown 
violently  to  the  ground.  The  wound  of  exit  is  similar  to  the  wound  of 
extrance.  There  was  very  slight  hemorrhage.  A  few  minutes  after 
receiving  the  injury  was  carried  from  the  firing  line  by  members  of  his 
<;ompany.  Removed  to  the  first  Division  Hospital  and  during  this 
time  was  conscious  of  his  wound  for  the  first  time.  Was  kept  there 
for  ten  days  and  then  removed  in  an  ambulance  seven  miles  over  a 
bad  road  to  the  third  Division  Hospital  at  Siboney." 

We  examined  him  July  10,  and  found  his  condition  very  much  as 
described  by  the  surgeon  on  the  Relief  on  July  11,  which  reads  as 
follows:  "Patient  was  voiceless  and  making  constant  efforts  to  clear 
his  bronchial  tubes  of  accumulated  mucus.  Complete  paralysis  of 
right  arm  and  leg  and  partial  loss  of  power  of  left  arm  and  leg.  Grip 
of  left  hand  very  feeble.  Respiration  normal  but  an  almost  constant 
spasmodic  cough.  Has  lost  control  of  sphincters  and  has  involuntary 
passages  from  both  bladder  and  bowels.  In  a  very  exhausted 
condition  and  has  profuse  diaphoresis.  Complains  of  pains  all 
over  body.  Ordered  a  hypodermic  of  morphia,  gr.  1/4  and  atropin 
gr.  1/100." 

"July  14:  Radiograph  taken  by  Dr.  Gray  shows  an  injury  of 
one  of  the  cervical  vertebrae,  probably  the  fifth.  Injury  seems  to  be 
to  the  left  side  of  the  body  of  the  bone.  Has  received  no  treatment 
other  than  complete  rest  and  a  nightly  hypodermic  as  noted  above, 
which  gives  a  good  night's  sleep  and  markedly  reduces  the  sweating. 
Has  regained  control  of  the  sphincters  and  is  able  to  use  bed  pan  and 
urinal." 

"July  19:  During  the  past  six  days  there  has  been  a  decided 
improvement  in  the  general  condition  of  the  patient.  He  is  brighter 
in  appearance,  he  can  articulate  more  distinctly  and  there  is  a  decided 
return  of  power  in  the  right  leg.  The  right  hand  is  still  absolutely 
powerless  but  the  grip  of  the  left  hand  is  stronger.  Appetite  is  good  and 
bowels  require  to  be  moved  with  enemas.     Unable  to  sleep  without 


GUNSHOT    WOUXDS    OF    THE    SPIXE  207 

morphine  but  the  atropin  has  been  discontinued.  Circulation 
apparently  unimpaired." 

"July  21:  Improvement  in  general  condition  still  continues.  The 
external  wounds  have  healed  so  well  that  they  are  not  noticeable  ex- 
cept on  close  inspection.  The  hypodermics  have  been  discontinued 
and  trional  and  sulphonal  substituted." 

"July  22:  Transferred  from  hospital  ship  Relief  to  hospital, 
Fort  Porter,  X.  Y.  The  subsequent  history  of  the  case  shows  a  gradual 
restoration  of  function  of  arms,  legs,  and  sphincters.  This  officer  had 
recovered  sufficiently  in  the  course  of  a  j^ear  to  be  detailed  as  instructor 
in  one  of  our  military  schools.  He  was  later  retired  the  service  and 
died  Januarj',  1906,  7  12  years  after  the  injury,  cause  not  stated. 
We  have  ever^^  reason  to  believe  that  the  lesion  in  this  and  the  follow- 
ing case  was  due  to  vibratory  concussion  of  the  cord  as  described  b}^ 
Mr.  Makins. 

Pvt.  A.  F.,  Co.  "C",  21st  Infantry,  shot  at  battle  of  Calamba, 
P.  I.,  July  30,  1899,  by  a  :\Iauser  bullet  distance  250  yards.  The 
bullet  entered  right  chest  above  nipple,  over  fourth  intercostal  space 
and  passed  downward,  backward  and  to  the  left,  emerging  from 
back  1  inch  to  the  left  of  the  second  lumbar  spine.  Left  leg  totally 
paralyzed  immediately  after  injury,  hemoptysis  two  days  later. 
Wound  healed  rapidly  without  suppuration.  Sensation  returned  in 
leg  two  months  after  injury  and  motion  also  returned  in  the  course 
of  another  month.  Examination  by  the  ^\Titer  in  ^Nlay,  1901,  revealed 
weakness  of  the  left  leg  as  compared  to  the  right,  pains  shooting  down 
left  leg  and  into  corresponding  big  toe.  Patellar  reflex  absent  on  left, 
increased  on  right  side.  Ankle  clonus  absent  on  both  sides.  Plantar 
reflex  absent  on  left  side.  The  patient  was  improving  when  last  seen 
some  months  later. 

Symptoms. — The  symptoms  of  gunshot  injuries  of  the  spine  may 
be  divided  into  those  pertaining  to  lesion  of  the  vertebrae  without 
cord  involvement,  and  those  T^dth  cord  involvement. 

Symptoms  without  Cord  Involvement. — This  form  of  injury  was 
more  evident  by  the  presence  of  signs  and  symptoms  from  the  effects 
of  the  old,  larger-caliber  lead  bullets.  As  a  rule  the  degree  of  com- 
minution and  displacement  increases,  with  the  caliber  and  weight  of 
the  missile,  and  danger  to  infection  is  greater.  Fracture  of  the  neu- 
ral arches  "^dthout  cord  involvement  rarely  occurs,  while  fracture  of 
the  centra  or  processes  is  apt  to  occur  T^ithout  cord  involvement  when 
the  velocitj"  of  the  bullet,  whether  it  be  a  large  or  small  caliber,  is  low. 


208  GUNSHOT   WOUNDS 

As  stated  already,  lesion  of  the  centra  by  the  reduced-caliber  bullet 
is  attended  ■v^dth  perforation  and  no  splintering,  and,  except  when  the 
bullet  is  animated  by  high  velocity,  there  is  no  cord  involvement 
unless  the  perforation  communicates  with  the  spinal  canal.  Many 
cases  of  vertebral  injury  are  apparent  only  from  a  study  of  the  track 
of  the  bullet  as  determined  by  direction  of  the  wounds  and 
the  position  of  the  body  at  the  time  of  injury.  Separation  of  the 
spinous  processes  may  be  indicated  by  deformity,  pain  on  pressure, 
mobility  and  crepitation.  Angular  deformity  is  rare  in  injuries  by  the 
reduced-caliber  bullet,  compared  to  the  lesions  by  the  old-time  pro- 
jectile of  larger  caliber  of  the  Springfield  rifle  type.  One  or  more 
vertebrae  may  be  implicated,  and  in  the  wars  of  to-day  when  men  do 
much  fighting  in  the  prone  position,  sagittal  wounds  involving  a  num- 
ber of  the  processes  or  bodies  are  common.  Injuries  to  the  nerve  roots 
T\dll  be  discussed  in  the  chapter  on  Injury  to  Nerves. 

Symptoms  with  Cord  Involvement. — The  symptoms  of  vertebral 
lesion  with  cord  involvement  from  gunshots  are  the  same  as  those  in 
fracture-dislocation,  observed  in  civil  hospitals  from  other  causes. 
Like  the  latter  the  symptoms  vary  with  the  region  injured.  Generally 
speaking  they  may  be  summed  up  as  follows:  When  the  spinal  cord 
suffers  violent  concussion,  laceration,  or  compression,  as  a  result  of 
gunshot  there  is  more  or  less  shock  with  complete  paralysis  below  the 
seat  of  injury  which  takes  place  at  once.  The  paralysis  includes  all 
muscles  supplied  by  the  injured  segment  and  the  segments  below. 
Lesion  of  the  cervical  region  is  attended  with  paralysis  of  the  upper 
and  lower  extremities.  If  the  dorsal  region  is  implicated,  paraplegia 
takes  place.  In  partial  lesions  one  arm  and  one  leg  may  show  a  greater 
degree  of  paralysis.  Again  the  paralysis  may  show  itself  chiefly  in 
both  arms,  or  chiefly  in  one  arm,  or  leg.  As  a  rule  complete  paralysis 
follows  extensive  lesions,  which  continues  till  death.  At  times  the  con- 
dition is  that  of  complete  paralysis  of  the  extensors,  and  from  the  first 
there  is  ability  to  flex  the  fingers  and  toes,  or  the  ability  to  do  so  may 
manifest  itself  later.  The  type  of  paralysis  varies  with  the  extent  of 
the  injury  and  the  location  thereof.  In  the  lower  lumbar  and  sacral 
regions  the  form  of  paralysis  is  flaccid  with  tendency  to  atrophy.  At 
higher  levels  the  tendency  in  extensive  cord  lesions  is  for  the  paralysis 
to  be  flaccid  at  first  only,  later  as  recovery  takes  place  it  assumes  the 
neuron  type.  There  are  sensory  symptoms  which  consist  of  hyper- 
esthesia, anesthesia,  numbness,  formication  or  a  sensation  of  pricking 
with  pins  and  needles.     The  pain  which  is  usually  local  may  be  in- 


GUNSHOT    WOUNDS    OF   THE    SPINE  209 

tensified  by  movement.  Often  times  there  is  no  pain.  Radiating  pains, 
generally  brought  on  by  movement  of  the  extremities,  are  apt  to  occur 
in  cases  of  partial  paralysis,  more  especially  of  the  arms.  The  ap- 
pearance of  numbness,  tingling  and  pain  to  touch,  in  a  case  of  complete 
loss  of  sensation,  are  regarded  as  of  favorable  prognostic  value.  In 
severe  cases  there  is  often  the  so-called  girdle  sensation,  which  results 
from  a  zone  of  hyperesthesia  immediately  above  the  limit  of  total 
anesthesia.  The  thermic  sense  is  sometimes  lost  or  diminished, 
while  the  sense  of  touch  still  exists.  When  anesthesia  is  permanent 
the  chances  of  recovery  are  bad.  The  reflexes  are  diminished  or 
abolished  when  the  lesion  is  located  in  a  region  of  the  cord  in  which  the 
reflex  emanates.  For  instance  in  lesion  of  the  lumbar  region  the  knee 
jerk  is  diminished  or  entirely  absent.  In  the  same  way  the  cremas- 
teric, plantar,  and  other  reflexes  when  diminished  or  absent  point 
to  the  particular  part  of  the  cord  involved. 

Genito-urinary  sj^mptoms  refer  to  those  of  the  bladder.  Retention 
of  urine  is  a  common  symptom  in  a  large  percentage  of  spinal-cord 
injuries.  This  is  later  followed  by  incontinence  due  to  overflow. 
When  the  paralysis  persists,  instrumentation  becomes  necessary,  this 
sets  up  cystitis  as  a  rule,  and  the  latter  tends  to  alkaline  urine  and  a 
tendency  to  the  formation  of  vesical  calculi.  Sexual  sensations  are 
usually  lost.  Priapism  is  frequent  in  severe  injuries  of  the  cord 
substance,  and  also  when  the  lesion  is  located  in  the  cervical  region. 

Herpes  zoster  is  an  occasional  trophic  symptom.  The  paralyzed 
limbs  are  apt  to  be  dry  and  scaly,  and  the  growth  of  the  nails  is  impaired. 
Decubitus  is  the  most  important  of  the  trophic  symptoms.  It  is 
most  frequent  over  the  buttocks,  heels  and  external  malleoli,  the 
elbows  and  shoulders,  parts  where  pressure  is  constant.  Bed-sores 
develop  rapidly,  as  early  as  the  first  twenty-four  hours  in  some  cases. 
Sloughing  is  assisted  by  infection  and  it  is  very  rapid  in  the  surrounding 
tissues.  Septic  fever  generally  hastens  the  termination  of  the  case. 
Cyanosis  is  prone  to  occur,  especially  in  lesion  of  the  lumber  region. 
The  temperature  is  elevated  early  in  the  history  of  some  cases  and  it 
ascends  with  the  height  of  the  lesion  in  the  cord.  In  cervical  lesions 
it  registers  as  high  as  108°  F.  a  few  hours  after  the  injury. 

Dryness  of  the  lips  and  mouth  with  sores  on  the  lips  sometimes  oc- 
curs but  the  distention  of  the  intestines  by  gas  is  the  most  important 
symptom  relating  to  the  digestive  system.  It  is  a  serious  symptom 
at  times  because  of  the  hindrance  which  it  offers  to  respiration.  It 
occurs  when  the  lesion  is  located  in  the  cervical  and  dorsal  regions, 


210  GUNSHOT   WOUNDS 

and  it  never  results  from  lumbar  and  sacral  lesions.  It  does  not  appear 
until  about  twelve  hours  after  the  receipt  of  the  injury.  Constipation 
is  the  rule  but  incontinence  of  feces  may  supervene  later. 

The  pulse  is  at  first  accelerated  and  full,  and  it  may  intermit. 
The  respiratory  symptoms  come  from  paralysis  of  the  muscles  of 
respiration  and  inability  to  relieve  the  accumulation  of  mucus  in  the 
larynx  and  trachea.  Later  edema  and  congestion  of  the  lung,  fruitful 
causes  of  death,  are  apt  to  supervene.  Contracted  pupils  are  common 
in  lesion  of  the  cord  in  any  region.  When  the  cervical  sympathetic 
is  involved,  as  pointed  out  already  when  discussing  lesions  of  this 
nerve  in  the  neck,  there  is  narrowing  of  the  palpebral  fissure. 

Diagnosis. — The  diagnosis  of  spinal-cord  injury  will  necessarily 
rest  upon  a  consideration  of  the  symptoms  just  noted.  In  addition 
X-ray  evidence  may  assist  in  detecting  the  site  of  pressure  by  spiculse 
of  bone  or  lodged  missile. 

Prognosis. — A  guarded  prognosis  should  be  given  in  all  cases, 
even  in  those  where  the  symptoms  point  to  slight  injury.  When  the 
lesion  is  pure  concussion  or  the  result  of  parenchymatous  hemorrhage, 
the  remote  effects  are  difficult  to  foretell;  and  the  danger  of  secondary 
changes  in  the  cord  are  to  be  remembered.  Meningeal  hemorrhage 
independently  of  complications  like  meningitis  is  not  specially  fatal. 
Medullary  hemorrhage,  causing  but  partial  symptoms  of  transverse 
lesion,  may  end  in  recovery,  with  remote  and  ulterior  disabling  conse- 
quences. Pressure  from  spiculse  of  bone  is  unfavorable,  when  the 
ball  passing  adjacent  to  the  cordis  animated  with  a  high  velocity. 
Pressure  from  a  lodged  missile  is  not  necessarily  fatal,  if  the  symptoms 
of  transverse  lesion  are  incomplete,  and  secondary  changes  remain 
absent.  The  renjote  effects  in  the  following  case  of  injury  to  the 
lower  part  of  the  cord  make  it  worthy  of  mention:  Mr.  Edward  M., 
New  York  Journal  reporter,  was  shot,  July  24,  by  a  Mauser  bullet  at 
Las  Guasimas  during  the  advance  on  Santiago.  The  bullet  entered 
the  back  1  inch  to  the  left  of  the  spine  opposite  the  sacro-lumbar 
articulation.  There  was  immediate  and  complete  paralysis  of  motion 
and  sensation  of  the  lower  extremities.  We  transferred  the  patient 
from  the  Reserve  Divisional  Hospital  at  Siboney  to  the  hospital  ship 
Olevette  June  9.  He  entered  St.  Lukes  Hospital,  New  York,  July  20, 
for  paraplegia  and  partial  anesthesia  as  a  result  of  the  gunshot  wound. 
A  radiograph  taken  at  this  time  showed  the  bullet  lodged  butt  end 
foremost  1  inch  to  the  right  of  the  first  lumbar  vertebra.  August  13 
he  was  able  to  move  the  right  leg.     August  17  Dr.  Abbe  performed  a 


GUNSHOT   WOUNDS    OF   THE    SPINE  211 

laminectomy  in  the  lower  dorsal  and  upper  lumbar  region,  cutting 
through  the  laminae  of  four  vertebrae  on  one  side  and  breaking  the 
laminae  on  the  opposite  side.  A  small  spicule  of  bone  pressing  on  the 
cord  was  removed. 

He  left  St.  Lukes  Hospital  October  10  very  much  improved.  He 
was  able  to  walk  with  assistance;  his  left  leg  was  weak  and  more  or 
less  useless.  June  30,  1912,  fourteen  years  after  the  injury,  Mr. 
Marshall  writes  as  follows: 


You  may  or  may  not  know  that  a  year  after  the  spinal  operation 
I  took  matters  into  my  own  hands  and  arranged  with  other  surgeons 
for  the  amputation  of  my  left  leg  midway  between  the  knee  and  ankle. 
The  results  of  this  amputation  were  so  good  that  I  was  encouraged  to 
hope  that  despite  the  predictions  of  my  medical  friends  I  might  learn 
to  walk.  I  therefore  went  out  to  the  Michigan  woods  with  a  man  who 
kept  whitewashed  steps  painted  on  the  grass  for  me  in  a  row  between  two 
railings  which  served  in  lieu  of  crutches.  After  nearly  five  years, 
practice  at  these  footsteps,  I  came  east  again  under  my  own  steam, 
carrying  only  one  cane.  Since  then  my  health  has  steadily  improved 
and  I  have  hopes  that  next  year  I  may  be  able  to  discard  the  single 
cane. 


Very  sincerely  yours, 

(Signed)  Edward  Marshall. 
Colonel  Louis  A.  La  Garde, 

Commandant,  Army  Medical  School,  U.  S.  A., 
Washington,  D.  C. 
As  stated  already  cervical  and  dorsal  lesions  give  the  worst  prog- 
nosis. All  cases  in  these  regions,  in  which  the  symptoms  point  to 
transverse  lesion,  die  in  the  course  of  about  six  weeks.  The  fatality 
in  gunshot  of  the  spine  is  often  augmented  by  the  involvement  of 
important  structures  in  the  abdomen,  chest  or  neck.  The  causes  of 
death  are  direct  or  indirect  lesions  in  the  upper  parts  of  the  cord 
from  which  the  respiratory  muscles  become  involved.  Hemorrhage 
in  various  forms — intra-dural,  extra-dural,  and  hemato-myelia;  menin- 
gitis, myelitis,  cystitis,  pyelitis,  surgical  kidney,  extreme  decubitus, 
and  septicemia,  all  figure  among  the  causes  of  death. 

Treatment. — After  the  necessary  precautions  have  been  taken  to 


212  GUNSHOT    WOUNDS 

avoid  sepsis,  the  treatment  of  gunshot  of  the  spine  is  largely  expectant. 
When  the  wound  is  located  on  the  back,  and  inflicted  by  a  shell  frag- 
ment or  large  projectile,  the  dangers  of  infection  are  very  much  in- 
creased, and  the  accessible  parts  of  the  wound  should  be  carefully 
guarded  by  frequent  dressing,  Hberal  drainage,  as  well  as  irrigation, 
if  laceration  is  present. 

Transport  of  spinal  cases  should  be  deferred  for  the  purpose  of 
avoiding  hemorrhage,  if  for  nothing  else,  as  long  as  possible,  and  when 
it  becomes  necessary  to  move  these  grave  cases,  they  are  better  carried 
on  stretchers  to  the  nearest  point,  where  appropriate  after-treatment 
may  be  properly  conducted.  Whenever  practicable,  the  patient 
should  be  placed  on  a  fracture  bed.  The  general  measures  of  treatment 
in  gunshot  cases  do  not  differ  from  fracture  which  may  have  resulted 
from  other  causes.  Constipation  should  be  relieved  by  enemata  and 
appropriate  catharsis,  as  often  as  indicated.  The  distended  bladder 
should  be  relieved  every  six  hours  by  the  use  of  a  rubber  catheter 
under  strict  rules  to  prevent  infection  of  the  viscus.  Pressure  bed- 
sores should  be  avoided  by  watchful  care,  and  when  threatened  they 
should  be  treated  in  the  ordinary  way.  Bed-sores  of  trophic  origin 
should  be  kept  clean  and  frequently  dressed. 

Unlike  the  cases  of  spinal  injury  from  fracture  dislocation  in  civil 
hospitals,  those  from  gunshot  by  the  reduced-caliber  bullets  especially 
require  no  mechanical  appliance  to  maintain  extension  and  counter- 
extension  for  the  reason  that  as  a  rule  there  is  no  displacement  that 
can  be  detected. 

Operative  interference  in  war  wounds  of  the  spine  has  yielded  poor 
results.  Now  that  the  transmission  of  energy  from  the  projectiles  of 
the  high-power  mihtary  rifles  is  known  to  be  a  definite  factor  in  pro- 
ducing complete  transverse  lesion  in  which  concussion,  contusion 
without  pressure,  and  hemato-myelia,  play  the  principal  role,  the 
futility  of  performing  laminectomy,  except  for  very  definite  reasons, 
is  at  once  apparent.  In  recent  wars  those  subjected  to  the  knife 
have  died  as  a  rule.  Possibly  the  operation  did  not  hasten  the  end, 
but  we  know  that  in  the  large  majority  of  the  cases  no  operation  was 
indicated.  Fallenfant^  informs  us  that  in  five  primitive  laminectomies 
which  he  saw  at  Moukden,  death  occurred  rapidly.  He  saw  no 
secondary  operations.  The  experience  of  the  British  surgeons  in  the 
Anglo-Boer  War  was  no  better.  We  did  no  laminectomies  following 
the  battle  of  Santiago,  as  nearly  all  the  cases  in  which  the  cord  was 

1  Op.  cit. 


GUNSHOT   WOUNDS    OF   THE    SPINE  213 

seriously  involved  with  fracture  died  before  reaching  hospitals,  or 
soon  thereafter. 

In  the  light  of  our  present  knowledge,  an  operation  such  as  a 
formal  laminectomy  is  only  indicated  when  symptoms  of  irritation 
and  compression  are  present.  Compression  from  blood  clot  may  be 
indicated  by  the  clinical  history,  and  compression  from  spiculse  of 
bone  or  a  lodged  missile  may  be  indicated  by  the  history,  and  X-ray 
evidence  as  well. 

Surgeons  are  often  tempted  to  perform  exploratory  operations  in 
gunshot  of  the  spine,  and  yet  Mr.  Makins  informs  us  that  he  saw  but 
one  case  in  his  whole  series  in  which  it  ''seemed  possible  to  regret 
the  omission  of  an  exploration." 


CHAPTER  VIII 
Gunshot  Wounds  of  the  Chest 

With  the  use  of  the  old  armament  chest  wounds  numbered  8  per 
cent,  of  all  wounds  treated  in  war  hospitals.  This  percentage  is 
greater  with  the  use  of  the  new  armament  and  the  present-day  field 
tactics,  which  favor  fighting  in  the  prone  position  behind  shelter 
during  which  the  upper  part  of  the  body  is  more  frequently  and  longer 
exposed.  There  is  also  reason  to  believe  that  the  mortality  from 
internal  primary  hemorrhage  will  be  greater  on  the  field  of  battle 
than  formerly  as  a  result  of  the  clean-cut  character  of  the  wounds 
of  the  larger  vessels  in  the  chest. 

The  mortality  for  all  chest  wounds  was  comparatively  large  in 
the  days  of  the  old  armament.  Otis  places  it  at  27.8  per  cent,  for  the 
Civil  War.  This  includes  wounds  of  the  thorax,  contused,  non- 
penetrating and  penetrating  wounds  of  the  chest.  Under  modern 
conditions  this  fatality  was  reduced  to  9.5  per  cent,  in  the  Spanish- 
American  War.  At  Santiago  we  found  gunshot  wounds  of  the  chest 
to  be  the  most  favorable  of  all  trunk  injuries  outside  of  the  heart  and 
great  vessels.  We  believe  this  to  be  the  experience  of  the  majority  of 
surgeons  in  recent  wars. 

For  the  purpose  of  more  careful  study,  gunshot  wounds  of  the  chest 
are  divided  into  (1)  non-penetrating  and  (2)  penetrating. 

Non-penetrating  wounds  of  the  chest  include  (a)  Contusions  in 
which  there  is  no  laceration  or  penetration  of  the  skin,  and  (b)  Wounds 
including  laceration  or  penetration  of  the  skin  without  involvement  of 
the  pleural  cavity. 

(a)  Contusions  of  the  chest  wall  are  usually  trivial  unless  the 
force  of  impact  and  size  of  the  projectile  are  sufficient  to  rupture 
underlying  tissues,  or  to  fracture  bones.  Projectiles  with  a  large 
smooth  surface  have  been  known  to  strike  and  contuse  the  chest  with 
violence  enough  to  rupture  the  heart,  lungs  or  great  vessels,  causing 
immediate  death.  Contusions  by  smaller  projectiles  have  also  been 
known  to  make  such  pressure  on  impact  as  to  cause  rupture  of  vessels 

214 


GUNSHOT   WOUNDS    OF   THE    CHEST  215 

in  the  lung  tissue,  and  visceral  pleura  with  resulting  hemoptysis, 
pneumo-thorax,  hemothorax,  emphysema,  pleuritis  or  pneumonia. 

Treatment. — Contusions  of  the  chest  seldom  require  active  treat- 
ment. When  shock  and  collapse  are  present  the  condition  should 
be  treated  accordingly.  The  chest  wall  on  the  affected  side  should 
be  immobilized  by  strapping.  If  hemothorax  and  pneumothorax 
should  appear  the  use  of  the  aspirator  is  indicated  in  urgent  cases 
with  a  view  to  removal  of  the  blood  and  air. 

(b)  Laceration  and  penetration  of  the  chest  wall  without  involve- 
ment of  the  pleura  in  the  wound  occurred  in  11,549  cases  out  of 
20,364  flesh  and  penetrating  gunshot  wounds  of  the  chest  in  the  Civil 
War  with  a  mortality  of  1  per  cent.  Under  modern  conditions  we 
will  expect  no  mortality  from  this  class  of  wounds.  Shell  fragments, 
deformed  bullets  and  shrapnel  balls  are  for  the  most  part  slow-moving 
projectiles  which  are  prone  to  lodge,  they  inflict  lacerated  wounds 
which  correspond  in  size  to  the  shape  and  caliber  of  the  missile  inflicting 
them.  These  wounds  are  usually  badly  infected  and  they  require 
the  special  attention  of  the  surgeon  to  prevent  suppuration.  At  the 
same  time  that  wounds  of  the  chest  walls  are  not  fatal,  they  heal 
slowly  because  of  interference  to  the  process  of  repair  by  the 
respiratory  movements. 

In  the  Santiago  campaign  wounds  of  the  chest  wall  by  the  reduced- 
caliber  bullet  were  often  multiple  and  owing  to  the  projectiles'  superior 
penetration,  lodged  balls  were  seldom  seen.  Sagittal,  oblique,  and 
transverse  shots  were  frequent.  In  one  instance  the  projectile  entered 
the  breast  above  the  nipple,  emerged  below  it.  It  re-entered  at  the 
costal  margin  and  passing  under  the  skin  of  the  abdomen  it  emerged 
from  beneath  the  skin  above  Poupart's  ligament.  In  transverse  shots 
the  bullet  frequently  penetrated  the  arm  and  chest  wall,  inflicting 
injury  to  ribs  and  cartilage  without  penetrating  the  chest  or  thorax. 

Treatment  of  non-penetrating  wounds  of  chest  wall  is  similar  to 
that  of  simple  gunshot  wounds.  They  seldom  require  more  than  a 
first-aid  dressing.  Foreign  bodies,  lodged  missiles,  etc.,  should  be 
removed,  and  strict  antisepsis  should  be  practised.  Bleeding  vessels 
should  be  tied  andwhen  pain  is  present  immobilizing  the  chest  wall  by 
strapping  will  prove  very  effective. 

Penetrating  wounds  of  the  chest  were  very  fatal  in  the  Civil  War 
and  the  wars  fought  with  the  old  armament.  Otis  makes  record  of 
8715  cases  treated  with  a  mortality  of  62.5  per  cent.  The  French 
Army  had  a  mortality  list  of  91.6  per  cent,  in  the  Crimea;  and  the 

15 


216  GUNSHOT   WOUNDS 

English  troops  suffered  a  mortality  of  79.2  per  cent,  in  the  same 
campaign.  Generally  speaking,  60  per  cent,  of  the  penetrating  gun- 
shot wounds  in  former  wars  died.  In  campaigns  which  entailed 
privations  on  account  of  weather,  lack  of  proper  nursing  and  above  all, 
enforced  transport  in  all  kinds  of  uncomfortable  vehicles,  the  mor- 
tality was  rated  above  90  per  cent.  The  humane  character  of  the 
reduced-caliber  bullet  in  visceral  wounds  is  nowhere  better  exhibited 
than  it  is  in  those  penetrating  gunshot  wounds  of  the  chest  that  survive 
to  reach  hospital  treatment.  Out  of  283  cases  reported  from  the 
Spanish-American  War  and  Philippine  Insurrection  our  mortality 
was  27.5  per  cent,  as  compared  to  62.5  per  cent,  in  the  Civil  War. 
Better  still,  Stevenson  reports  that  out  of  214  cases  which  were  treated 
in  the  Boer  War  only  thirty  died,  making  the  death  rate  14  per  cent. 
The  variation  in  the  death  rate  of  these  two  campaigns  may  be  due 
to  the  distribution  of  the  relief  personnel  with  the  army.  With  us 
at  the  battle  of  Santiago  especially,  our  surgeons  had  their  dressing 
stations  close  to  the  fighting  line.  The  severely  wounded  who  would 
ordinarily  have  died  on  the  field  were  treated  and  noted  as  cases 
belonging  to  those  treated  in  hospitals.  The  same  explanation  holds 
good  for  the  part  of  the  war  in  the  Philippines — our  surgeons  took 
note  of  the  wounded  on  the  line  as  soon  as  they  were  hit,  hence  the 
larger  percentage  of  fatalities. 

The  humane  character  of  gunshot  wounds  as  revealed  in  late  wars 
was  most  gratifying  to  us  because,  as  already  stated  in  another  chapter, 
experimental  studies  with  the  factors  concerned  in  causing  destructive 
effects  in  wounds  had  led  us  to  predict  a  favorable  outcome  in  gunshot 
wounds  of  the  lungs.  The  small  frontage  of  the  jacketed  bullets  of 
reduced  caliber  and  the  minimum  amount  of  resistance  in  lung  tissue 
favor  the  occurrence  of  humane  wounds.  Military  surgeons  in  the 
Anglo-Boer  and  Russo-Japanese  Wars  all  agree  upon  this  point. 
Oettingen^  from  the  Manchurian  campaign  says  that  when  injuries 
of  the  lungs  were  simple,  they  were  among  the  most  harmless  of  those 
met  in  war.  Fallenfant^  collected  the  results  in  945  gunshot  wounds 
of  the  lungs  and  pleura  in  the  hospitals  at  Moukden  with  a  mortality 
of  3.67  per  cent.  He  states  that  a  certain  number  of  officers  and  men 
were  able  to  resume  their  duties  in  a  few  weeks.  Graf  and  Hilde- 
brandt^  mention  the  case  of  a  Chinese  soldier  who  had  strength  suffi- 

1  Op.  cit. 

2  Op.  cit. 

^  Graf  und   Hildebrandt.     Die  verwundungen  durch  die  modernen  Kriegs- 
feuerwaffen.     Vol.  II,  Berlin,  1907. 


GUNSHOT   WOUNDS    OF    THE    CHEST  217 

cient  to  swim  five  hours  after  receiving  a  fatal  gunshot  wound  of  the 
lung.  We  found  it  difficult  to  restrain  the  patients  shot  through  the 
chest  after  the  battle  of  Santiago.  Many  of  them  had  neither  dyspnea, 
pain,  nor  hemoptysis,  so  that  it  was  difficult  for  them  to  understand 
the  necessity  of  keeping  quiet.  While  inspecting  the  wards  of  our 
hospital  four  days  after  the  battle,  the  beneficence  of  wounds  by  the 
reduced-caliber  bullet  was  brought  forcibly  to  our  attention  when  we 
found  two  soldiers  late  in  the  night  sitting  on  the  ground  engaged  in 
conversation  over  the  events  of  the  battle,  while  smoking  cigarettes. 
One  of  them  had  been  shot  through  the  right  lung  and  the  other  had 
received  a  perforating  gun-shot  of  the  cranium  over  the  parietal 
region.  The  latter  had  been  operated  upon  that  day  for  the  removal 
of  loose  fragments  of  bone  at  the  wound  of  entrance. 

We  had  some  remarkable  recoveries  from  gunshot  wounds  of  the 
chest  as  follows: 

In  the  case  of  Pvt.  E.  0.,  Company  "C",  16th  Infantry,  the  ball, 
a  .45-caliber  shrapnel,  entered  just  below  the  angle  of  the  right  scapula 
and  coursing  forward  lodged  under  the  skin  in  front  between  the 
seventh  and  eighth  ribs  having  penetrated  the  lung,  diaphragm  and 
liver.  There  was  hemoptysis  for  a  few  days  and  slight  elevation  of 
temperature.  Lt.-Col.  N.  Senn,^  U.  S.  V.,  reported  the  temperature 
normal  on  the  tenth  day  and  recovery  seemed  near  completion  on  about 
the  nineteenth  day. 

Pvt.  J.  B.  Senacal,  Co.  "G",  22d  Infantry,  was  shot  by  a  Spanish 
Mauser  bullet  on  July  1.  The  bullet  entered  the  back  just  below  the 
angle  of  the  left  scapula.  It  ranged  upward  through  the  lung,  neck 
and  lower  jaw,  making  its  escape  through  the  alveolar  process  opposite 
the  right  bicuspid,  furroT\ang  the  tongue.  We  saw  this  case  shortly 
after  the  occurrence.  He  suffered  from  partial  paralysis  of  the  left 
arm  as  a  result  of  injury  to  the  brachial  plexus.  There  was  profuse 
hemoptysis  for  the  first  few  days.  Recovery  was  uninterrupted  after 
the  third  week.  He  is  living  and  pensioned  at  the  rate  of  $30  per 
month. 

Private  Harry  Mitchel,  Co.  ''C",  7th  Infantry,  wounded  July  1, 
by  a  Mauser  bullet  entering  over  left  acromion  process,  and  passing 
through  the  apices  of  both  lungs.  The  bullet  escaped  from  the  chest 
wall  at  the  fourth  intercostal  space  just  above  the  right  nipple. 
There  was  moderate  hemothorax  right  side.  This  man  made  a  good 
recovery.     He  is  now  pensioned  at  the  rate  of  $24  per  month. 

^  Hispano-American  War,  letters  and  papers  by  N.  Senn.,  Surgeon  U.  S.  Vols. 


218  GUNSHOT   WOUNDS 

Henry  T.  Darby,  Co.  "D",  13th  Infantrj^,  received  a  gunshot 
wound  of  the  chest  on  right  side  from  a  Mauser  bullet  July  1.  Wound 
of  entrance  above  angle  and  to  outer  border  of  scapula.  The  bullet 
passed  transversely  forward  and  escaped  through  the  fourth  intercostal 
space  on  the  left  side  posterior  to  the  mammary  line.  He  was  trans- 
ferred to  the  hospital  ship  Relief  July  9,  at  which  time  Col.  Senn  re- 
ported his  condition  as  follows:  ''great  difficulty  in  breathing;  he  was 

pale,    prostrated,    temperature    102°   F copious   pleuritic 

effusion  on  left  side.  Chest  was  opened  by  an  incision  through  sixth 
intercostal  space  in  the  axillary  line  July  11.  About  3  pints  of  fluid 
blood  escaped.  Gauze  drainage.  The  lung  expanded  rapidly  and 
the  patient  commenced  to  improve."  He  was  subsequently  examined 
for  a  pension  and  rated  at  $30  per  month  until  1905,  when  he  was 
dropped,  whereabouts  unknown. 

Symptoms  and  Complications. — The  symptoms  of  perforating  gun- 
shot of  the  chest  are  extremely  variable.  In  some  cases  there  are 
but  few  symptoms. 

Shock  is  not  always  present,  but  it  seems  to  be  most  marked  in 
cases  with  a  pronounced  injury  to  the  chest  wall.  Pain  is  not  constant. 
It  is  sometimes  severe  when  fractured  ribs  complicate  the  chest  wound 
and  when  the  pleura  is  more  or  less  involved  in  the  trauma. 

Hemoptysis  is  present  in  about  75  per  cent,  of  the  cases,  according 
to  Stevenson's  observation  in  seventy-eight  cases.  It  lasts  three  or 
four  days  as  a  rule,  it  is  generally  scanty  and  seldom  calls  for  treat- 
ment. Cough  is  generally  slight,  and  of  short  duration.  Hemothorax 
is  a  common  complication  and  one  of  the  most  serious  when  it  is  copious 
and  persistent.  There  is  slight  hemorrhage  in  the  pleural  cavity  in 
nearly  every  case  of  pleural  involvement.  Such  cases  are  never  serious 
and  they  are  marked  by  early  convalescence.  Large  effusions  of  blood 
generally  arise  from  wounds  of  the  chest  wall  rather  than  the  lung  tis- 
sue. Makins  states  that  hemothorax  of  parietal  origin  occurs  in 
90  per  cent,  of  the  cases  as  a  result  of  direct  injury  to  intercostal  vessels 
by  the  projectile  or  from  laceration  by  pieces  of  fractured  ribs.  When 
it  arises  from  the  lung,  there  is  co-existent  hemoptysis.  The  onset  of 
hemothorax  is  gradual  as  a  rule,  and  it  seldom  occurs  before  the  second 
or  third  day.  It  is  a  recurrent  hemorrhage  and  like  recurrent  hemor- 
rhage in  other  parts  of  the  body  it  is  influenced  by  excitement,  transport, 
etc.  When  the  hemorrhage  issues  from  the  large  vessels  at  the  root 
of  the  lungs  the  hemothorax  occurs  immediately  and  it  is  rapidly 
fatal.     The  symptoms  indicating  the  appearance  of  hemothorax  are 


GUNSHOT   WOUNDS    OF    THE    CHEST  219 

rapid  pulse,  pain,  cyanosis,  dyspnea,  a  certain  degree  of  restlessness 
and  a  rise  of  temperature  which  at  first  is  ascribed  to  absorption  of 
fibrin.  It  has  been  noted  that  accessions  of  temperature  occurring 
later  from  time  to  time  may  be  due  to  fresh  hemorrhage  with  subse- 
quent absorptions  of  fibrin  and  not  to  sepsis.  The  remaining  symp- 
toms of  hemothorax  are  those  of  fluid  in  the  pleural  cavity.  Pneumo- 
thorax was  a  common  symptom  with  the  use  of  large-caliber  bullets 
but  it  is  seldom  observed  after  wounds  by  the  new  armament  because 
of  the  very  small  wounds  of  entrance  and  exit  in  the  lung  proper. 
Makins  saw  it  in  three  cases  out  of  about  a  half  dozen  wounded  by  the 
Martini  Henry  bullet  which  about  corresponds  to  our  old  .45-caliber 
450-grain  lead  bullet  shot  from  the  Springfield  rifle.  But  he  saw  the 
same  complication  in  less  than  3  per  cent,  of  perforating  chest  wounds 
by  the  reduced-caliber  jacketed  bullet.  Convalescence  was  slow  and 
tedious  in  those  injured  by  the  larger  caliber. 

Empyema  increases  in  frequency  with  the  caliber  of  the  bullet 
because  the  amount  of  dirt  and  infected  clothing  which  is  carried  in  the 
wound  is  in  proportion  to  the  sectional  area  of  the  bullet.  Infection 
may  also  come  from  bile  and  fecal  matter  when  the  projectile  traverses 
an  intestine  from  below.  Secondary  infection  sometimes  takes  place 
after  aspiration  or  incision  for  the  relief  of  hemothorax  or  removal  of  a 
lodged  ball.  Empyema  as  a  result  of  primary  infection  by  a  reduced- 
caliber  bullet  is  uncommon  unless  the  shot  is  delivered  at  proximal 
ranges  against  a  rib  with  shattering  of  bone.  In  such  a  case  the 
character  of  the  wound  augments  the  tendency  to  the  development 
of  infection  from  the  dirty  skin,  and  possibly  the  bullet. 

Pleurisy  and  Pneumonia. — Pleuris}^  is  very  rare.  A  certain 
amount  of  consolidation  necessarily  takes  place  about  the  channel  of 
a  gunshot  wound  in  lung  tissue,  but  pneumonia  as  a  clinical  entity  is 
seldom  seen  except  in  cases  followed  by  exposure. 

Abscess  of  the  lung  is  rare  from  gunshot  wound.  It  is  commonly 
associated  with  the  presence  of  foreign  bodies  like  fragments  of 
missiles,  bone,  or  pieces  of  clothing.  Lodged  bullets  have  been 
coughed  up  from  abscess  cavities  with  the  abscess  contents  and  again 
the  abscess  about  the  missile  may  point  outside.  Removal  of  the 
foreign  body  in  any  way  is  generally  followed  by  rapid  recovery. 
Gangrene  of  the  lung  is  a  very  rare  complication.  But  two  cases  were 
reported  in  the  Anglo-Boer  War,  both  ending  in  death. ^ 

1  Gunshot  Wounds  by  C.  G.  Spencer,  Major,  R.  A.  M.  C.  Henry  Frowde, 
Oxford  University  Press,  1908. 


220  GUNSHOT   WOUNDS 

Treatment. — The  first  indication  of  treatment  consists  in  the 
application  of  a  clean  dressing  to  a  clean  field.  The  patient  should  be 
kept  in  the  prone  position  and  propped  up  enough  to  insure  comfort. 
Transport  should  be  delayed  in  all  cases  until  healing  has  taken  place 
and  the  danger  to  complications  has  passed.  Our  cases  at  Santiago 
were  an  exemplification  of  the  evil  effects  of  early  tran.sport,  as 
pointed  out  by  Greenleaf^.  He  collected  the  history  of  twenty- 
four  cases  in  the  Santiago  campaign,  fifteen  of  whom  recovered  with- 
out complications.  Hemothorax  was  present  in  the  remainder,  and 
in  six  of  these  the  hemothorax  ended  in  empyema  as  a  result  of 
infection.  Our  wounded  were  on  the  move  from  the  time  they  were 
hit  until  they  were  received  in  the  hospitals  at  the  North.  They  were 
first  transferred  from  the  field  a  distance  of  ten  to  twelve  miles  over 
bad  roads  in  escort  wagons  mostly.  Upon  reaching  the  Divisional 
Hospital  at  Siboney,  they  were  transferred  in  small  boats  in  a  rough  sea 
to  transports  which  had  no  conveniences  for  the  care  of  the  sick,  as  a 
rule.  The  passage  to  northern  points  took  from  five  to  nine  days,  so 
that  during  the  active  stage  of  repair  the  wounds  were  seldom  quiet. 
Makins  states  that  under  favorable  field  conditions  hemothorax  occurs 
ordinarily  in  about  30  per  cent,  of  the  gunshot  cases  of  the  chest  and 
that  at  least  90  per  cent,  suffer  from  this  complication  in  varying  de- 
grees of  severity  when  early  transport  takes  place.  Manteuffel,^ 
Oettingen  and  all  the  reporters  from  Manchuria  agree  that  formal 
evacuation  is  contraindicated,  and  they  lay  particular  emphasis  on 
the  advisability  of  treating  chest  cases  near  the  first-aid  zone  whenever 
practicable. 

Fortunately  in  the  majority  of  cases  the  hemothorax  is  slight  and 
requires  no  active  surgical  interference.  With  rest  in  the  prone 
position,  and  morphine  when  indicated,  absorption  takes  place  in  a 
short  time.  It  is  a  safe  rule  to  delay  operation  for  some  days  to 
permit  healing  of  the  wounded  vessels,  otherwise  removal  of  the  blood 
from  the  pleural  cavity  is  apt  to  disturb  coagula  about  the  bleeding 
point  with  a  recurrence  of  hemorrhage.  When  the  blood  is  suf- 
ficient in  amount  to  embarrass  the  heart  or  the  respiratory  movements, 
it  may  be  removed  by  aspiration.  It  is  not  necessary  to  remove 
all  of  the  fluid  blood.     After  removing  it  in  part  absorption  of  the 

^  Gunshot  wounds  of  the  chest  in  the  Spanish-American  War  by  H.  S.  Green- 
leaf,  Asst.  Surg.,  U.  S.  A.,  N.  Y.  Med.  Jour.,  1899,  No.  70. 
2  Archiv.  flir  Chirurgie,  1906,  p.  711. 


GUNSHOT    WOUNDS    OF    THE    CHEST  221 

remainder  is  often  promoted,  and  if  it  does  not  disappear  entirely  the 
operation  may  be  repeated  a  second  or  third  time. 

The  source  of  hemorrhage  in  hemothorax  is  more  frequently  from 
the  intercostal  arteries  or  the  mammaries.  The  treatment  of  such  a 
condition  is  ligation  of  both  ends  of  the  bleeding  vessel.  In  cases  of 
hemorrhage  from  an  intercostal,  pressure  by  Desault's  method  which 
is  accomplished  by  pressing  the  center  of  a  square  piece  of  gauze  in 
the  wound  with  the  finger  and  subsequently  packing  the  pocket  left 
by  the  removal  of  the  finger  with  loose  gauze  is  a  very  effective  plan 
of  treatment.  The  corners  of  the  gauze  originally  pressed  in  by  the 
finger  are  pulled  upon  to  make  pressure  on  the  internal  surface  of  the 
wound  next  to  the  sternum  or  ribs.  The  neck  of  the  sack  thus  formed 
is  twisted  and  tied  close  to  the  chest  wall  and  subsequently  transfixed 
by  a  large  safety  pin. 

Failure  of  absorption  of  large  quantities  of  clotted  blood  should  be 
met  by  incision  or  the  resection  of  part  of  one  or  more  ribs  and  the 
subsequent  employment  of  irrigation.  When  a  hemothorax  undergoes 
suppuration  from  any  cause  the  treatment  is  the  same  as  that  for 
empyema — incision,  resection  of  rib,  drainage. 

All  operations  for  hemothorax  should  be  done  under  the  strictest 
antisepsis  with  reference  to  the  field,  the  instruments  and  dressings, 
to  prevent  infection  of  the  blood  clot,  which  is  proverbially  a  favorite 
pabulum  for  the  development  of  septic  microorganisms. 

Fractures. — -The  older  writers  placed  special  emphasis  upon  the 
gravity  of  penetrating  gunshot  wounds  of  the  chest  when  fracture  was 
present,  and  this  was  considered  especially  true  if  the  bone  lesion  was 
at  the  point  of  entrance.  It  was  also  believed  by  writers  during  the 
days  of  the  old  armament  that  a  perforating  gunshot  wound  of  the 
chest  could  not  take  place  without  fracture.  This  statement  in 
itself  shows  how  common  fracture  must  have  been  in  gunshots  by  the 
large  calibers.  Otis  states  that  out  of  8715  cases  of  penetrating  gun- 
shots of  the  chest,  fracture  of  the  ribs  is  noted  in  505  cases  of  which 
204  were  fatal.  He  believes  fracture  was  nevertheless  present  in  the 
majority  of  the  cases.  Fracture  of  the  sternum  is  noted  as  a  complica- 
tion in  fifty-one  cases,  fracture  of  the  vertebrae  in  ninety-two;  of 
the  clavicle  in  136,  of  the  scapula  in  375  cases  of  the  8715 
penetrating  chest  injuries. 

Fracture  of  the  ribs  by  the  reduced-cahber  bullets  is  in  the  form 
of  gutter,  or  notching  of  the  costal  margin.  When  complete  solution 
of  continuity  takes  place  the  comminution  is  localized,  the  spiculse 


222  GUNSHOT   WOUNDS 

are  small  and  the  fissures  are  short.  The  costal  cartilages  show  no 
fracture,  they  are  grooved  or  perforated.  Gunshot  of  the  sternum 
is  always  guttered  or  perforated,  without  fracture. 

Fracture  of  the  clavicle  is  attended  with  comminution  on  account 
of  its  compact  structure  and  the  area  of  fracture  is  not  so  circumscribed 
as  it  is  in  fracture  of  the  ribs.  In  the  case  of  Colonel  E.  H.  Liscum,  U. 
S.  A.,  at  the  battle  of  Santiago,  a  Spanish  Mauser  bullet  splintered  the 
middle  third  of  the  clavicle  badly.  Spiculae  of  bone  were  removed 
from  the  wound  shortly  after  the  injury  and  two  weeks  later  bone 
fragments  were  again  removed  and  the  jagged  edges  of  the  inner 
fragment  were  excised.  But  1  cm.  of  the  acromial  end  remained  after 
final  healing  (Johns  Hopkins  Hospital  records). 

Gunshot  lesion  of  the  scapula  generally  exhibits  clean-cut  perfora- 
tions with  no  special  features  as  to  symptoms  or  prognosis. 

Symptoms  of  Fracture  of  the  Ribs. — ^Fracture  of  the  ribs  often 
shows  none  of  the  symptoms  of  fracture  present  from  other  causes 
such  as  pain,  stitch  on  inspiration  or  crepitus.  This  fact  was  noticeable 
in  a  number  of  our  cases  in  the  Santiago  campaign.  The  absence 
of  symptoms  is  seen  especially  in  transverse  shots  through  the  chest. 
The  lesion  in  such  cases  may  be  perforation  or  notching.  In  either 
of  these  lesions  there  is  no  raison  d'etre  for  symptoms  of  pain  or 
crepitus.  Transverse  lesions  are  frequently  marked  by  complete 
solution  of  continuity  with  total  absence  of  bone  substance  opposite 
the  point  of  impact,  so  that  the  fragments  fail  to  touch.  In  such  cases 
crepitus  is  absent,  and  most  generally  pain  and  stitch  on  inspiration 
are  not  complained  of.  In  longitudinal  shots  complicated  by  complete 
fracture  of  two  or  more  ribs  the  comminution  is  generally  marked. 
In  these  cases  pain  and  dyspnea  are  often  severe. 

Treatment  of  Fractured  Ribs. — The  wound  should  be  explored  to 
remove  any  loose  spiculae  of  bone.  The  chest  should  be  immo- 
bilized at  once  in  all  cases.  The  indications  for  fixation  are  especially 
necessary  in  multiple  fractures. 

Lodgement  of  Bullets  in  the  Chest. — Retained  bullets  in  the 
chest  were  of  common  occurrence  with  the  use  of  the  low-velocity 
weapons.  Otis  in  his  series  of  8715  cases  of  penetrating  gunshot 
wounds  of  the  chest  mentions  484  cases  of  missiles  which  entered  the 
chest  and  which  were  believed  to  have  lodged  within.  His  notes 
contain  record  of  3463  cases  in  which  no  mention  is  made  as  to  exit  or 
lodgement.  In  the  wars  of  the  present  day  lodgement  of  missiles  is 
chiefly  confined  to  shell  fragments,  shrapnel  balls  and  rifle  projectiles 


GUNSHOT    WOUNDS    OF    THE    CHEST  223 

having  low  remaining  velocities.  Missiles  usually  find  lodgement  in 
the  chest  wall,  lung,  pleural  cavity  or  against  the  spinal  column. 
The  exact  location  of  the  foreign  body  is  first  to  be  determined  by  the 
X-ray.  No  attempt  should  be  made  to  remove  a  lodged  missile 
unless  it  causes  untoward  symptoms.  When  easily  accessible,  in  the 
chest  wall,  its  removal  should  be  undertaken  with  full  knowledge  of 
the  risks  involved  in  setting  up  sepsis  of  the  underlying  pleura,  and 
even  in  this  location,  if  the  projectile  causes  no  inconvenience  it  is 
better  to  let  it  remain  undisturbed  lest  infection  with  acute  empyema 
result  from  attempts  at  removal.  After  correctly  locating  a  missile 
inside  the  pleural  cavity,  if  it  gives  pain  and  other  symptoms  of 
irritation,  it  should  be  cut  upon  and  removed.  Projectiles  inbedcled 
in  lung  tissue  and  against  the  spine  are  best  let  alone. 

Gunshot  "Wounds  of  the  Heart  and  Pericardium. — When  a  gunshot 
wound  of  the  heart  occurs,  death  usually  results  in  a  very  few  moments. 
Still,  wounds  of  the  pericardium  and  heart  followed  by  recovery  were 
noted  even  in  the  days  of  the  old  armament.  The  marvelous  escape 
of  the  heart  and  pericardium  from  apparent  injury  in  shots  traversing 
the  cardiac  area  has  been  commented  upon  by  nearly  all  observers  in 
recent  wars.  These  cases  of  unexpected  recovery  are  said  to  be  due 
to  the  wa.y  in  which  the  heart  and  great  vessels  are  held  together  by 
loose  areolar  tissue  which  favors  a  certain  amount  of  displacement 
at  the  moment  of  impact  by  a  bullet  impressed  with  a  low  remaining 
velocity.  Some  of  the  unexpected  recoveries  from  wounds  of  the 
cardiac  area  have  also  been  ascribed  to  the  variability  of  the  size  of 
the  heart  from  systole  to  diastole. 

Follenfant^  states  that  Manteuffel  saw  five  cases,  and  that  Doctor 
Butz  observed  three  cases  of  wounds  of  the  heart  in  the  Manchurian 
campaign  which  recovered  ^vithout  treatment.  Makins  from  the 
Anglo-Boer  War  reports  that  "perforating  wounds  of  the  heart  were 
probably  fatal  in  all  instances,  in  spite  of  the  fact  that  in  some  patients 
who  survived,  the  position  of  wound  apertures  on  the  surface  of  the 
body  made  it  difficult  to  believe  that  the  heart  had  not  been  pene- 
trated." 

We  believe  Mr.  Makins'  statement  to  be  too  sweeping.  The 
literature  of  heart  injuries  contains  many  references  to  recovery  from 
incised  wounds  of  the  pericardium  and  heart.  If  recovery  from  gun- 
shot wounds  of  the  heart  were  possible  formerly  they  should  be  more 
apt  to  recover  now  from  the  lesions  inflicted  by  small  jacketed  bullets, 

1  Op.  cit. 


224  GUNSHOT   WOUNDS 

especially  those  of  the  6.5-mm.  bullet  of  the  Japanese,  or  the  later 
pointed  bullets  recently  adopted  by  the  English,  German  and  United 
States  armies  when  a  regular  impact  is  accomplished.  The  slit-like 
apertures  of  entry  and  exit  so  often  noted  in  the  skin  and  other  tissues 
are  not  unlike  incised  wounds  inflicted  by  a  knife  blade  from  which, 
as  we  have  already  stated,  authentic  instances  of  recovery  have  been 
noted. 

In  seventy-two  men  wounded  in  the  cardiac  area  Fischer  found 
the  location  of  the  wound  of  the  heart  on  post-mortem  to  be  as  follows: 

Right  ventricle 22 

Left  ventricle 16 

Both  ventricles 4 

Right  auricle 2 

Left  auricle 1 

Apex 1 

Base 1 

Septum  ventriculorum 1 

Entire  destruction  of  heart 1 

Symptoms. — Among  the  symptoms  of  wound  of  the  heart  and 
pericardium  are  those  of  great  distress,  shock,  irregular  action  of  the 
heart,  syncope,  dyspnea  and  severe  pain  in  the  cardiac  area.  Hemo- 
pericardium  when  present  more  often  appears  some  days  after  the  receipt 
of  the  injury.  At  first  the  fluid  blood  flows  through  the  pericardial 
wound  into  the  pleural  cavity  or  outside.  Later  when  the  pericardial 
wound  becomes  closed  by  coagula,  accumulation  of  blood  in  the  peri- 
cardium takes  place  and  the  symptoms  of  hemopericardium  appear, 
as  evidenced  by  increase  of  the  cardiac  area,  loss  of  apex  beat,  and 
the  presence  of  friction  sounds  from  the  inner  lining  of  the  pericardium 
rubbing  against  the  coagulated  blood.  In  cases  of  suppuration  the 
symptoms  are  very  similar,  with  the  added  presence  of  an  elevation 
in  temperature. 

Treatment. — When  symptoms  point  to  the  presence  of  blood  or 
septic  matter  in  the  pericardium  with  urgent  dyspnea,  paracentesis 
of  the  pericardium  should  be  practised  to  believe  the  distress  and  im- 
pending death.  The  needle  should  be  inserted  2  inches  to  the  left 
of  the  median  line  in  the  fourth  or  fifth  interspace,  pushing  it  continu- 
uously  until  no  further  resistance  is  encountered,  when  fluid  will 
flow  if  present.  The  patient  should  as  a  rule  be  recumbent  during 
the  operation.  The  operation  may  be  repeated  if  it  was  accompanied 
by  relief  in  the  first  instance.  If  pus  is  present  it  is  better  treated  by 
open  incision  and  drainage. 


GUNSHOT    WOUNDS    OF    THE    CHEST  225 

Wound  of  other  Thoracic  Structures. — Gunshot  wound  of  the 
thoracic  duct  does  not  figure  in  mecUcal  hterature.  Otis  reports  no 
instance  in  the  surgical  records  of  our  great  Civil  War,  and  we  find 
but  one  reference  to  such  a  case  in  the  experience  of  Bonet  as  quoted  by 
Delorme.^ 

Wound  of  the  thoracic  portion  of  the  esophagus  must  be  very 
rare.  Otis  mentions  one  solitary  instance  in  the  Civil  War.  Spencer 
stated  that  one  case  was  reported  from  the  Anglo-Boer  War  in  which 
dysphagia  was  the  only  symptom,  possiblj'-  as  a  result  of  bruising. 
Injury  to  the  thoracic  part  of  the  esophagus  in  battle  is  more  than  hkely 
accompanied  by  spinal  or  great-vessel  injuries  or  both,  cases  which 
figure  among  the  dead  on  the  field,  hence  their  rarity  in  military 
hospital  reports.  Again,  authors  cling  to  the  notion  that  the  loose 
tissue  of  the  mediastinum  permits  structures  like  the  great  vessels 
and  the  esophagus  to  be  pushed  aside  by  the  pressure  of  the  bullet. 
This  explanation  can  only  be  tenable  in  the  case  of  bullets  having 
low  remaining  velocities. 

iQp.  cit.,  pp.  719-20. 


CHAPTER  IX 

Gunshot  Wounds  of  the  Abdomen 

No  class  of  wounds  has  given  such  divergent  results  between  the 
practice  of  civil  and  military  hospitals  as  those  from  gunshot  of  the 
abdomen.  Our  civil  confreres  had  attained  results  in  the  surgical 
treatment  of  abdominal  wounds  mostly  from  pistol  shots  that  had 
served  to  lend  great  hope  for  the  outcome  of  abdominal  wounds  in- 
flicted by  firearms  in  modern  wars,  but  alas!  this  hope  was  turned  to 
bitter  disappointment  in  the  Spanish-American  War,  the  first  to  be 
fought  with  the  use  of  the  new  armament.  As  far  as  present  observa- 
tion and  experience  have  gone,  if  penetrating  wounds  of  the  abdomen 
in  the  field  recover  more  often  than  they  did  formerly,  we  regret  to  state 
that  it  is  not  through  the  intervention  of  surgical  care,  but  rather 
due  to  the  character  of  the  wounds  inflicted  by  the  new  military  rifle 
under  certain  battle  conditions  only,  and  that  the  skill  and  painstaking 
details  of  expert  surgeons  avail  but  little  in  the  management  of  the 
large  maj  ority  of  gunshot  wounds  of  this  region.  Various  reasons  have 
been  given  in  explanation  of  this  fact,  and  we  will  endeavor  in  this 
chapter  to  rehearse  the  points  at  issue  and  to  lay  emphasis  on  those 
which  appear  to  us  to  be  chiefly  concerned  in  this  unwelcome  result. 

Gunshot  wounds  of  the  abdomen  are  very  properly  divided  for  the 
purpose  of  study  into: 

(1)  Contusions. 

(2)  Non-penetrating  flesh  wounds. 

(3)  Penetrating  wounds  of  the  abdominal  cavity. 

(4)  Perforating  wounds  of  abdomen. 

(1)  Contusions  of  the  abdomen  may  be  (a)  confined  to  the  abdom- 
inal wall,  or  (b)  the  contusion  may  in  addition  be  accompanied  by 
rupture  or  other  injury  of  some  of  the  viscera  or  blood-vessels  in  the 
abdominal  cavity  proper.  Simple  contusion  of  the  abdominal  wall 
may  be  accompanied  by  superficial  extravasation  of  blood,  hematoma 
of  considerable  extent,  or  rupture  of  muscle  fiber.  As  a  result  of  gun- 
shot in  war,  the  condition  is  rare  as  compared  to  contusions  from 
other  causes,  such  as  that  attending  the  commotion  of  battle — vio- 

226 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  227 

lence  from  the  hools  of  horses,  the  wheels  of  field  artillery,  blows  from 
rifle  butts,  etc. 

Gunshot  contusions  of  the  abdomen  with  or  without  visceral  in- 
volvement are  caused  by  large  shot,  shells  or  shell  fragments  when 
moving  at  low  velocity,  or  in  a  direction  at  a  tangent  to  the  surface. 
They  also  arise  from  rifle  projectiles  and  shrapnel  balls  when  striking 
with  low  velocities  against  the  body  proper  or  part  of  the  accoutre- 
ment, like  a  belt  buckle. 

The  symptoms  of  contusion  may  be  attended  by  rupture  of  muscle 
which  is  indicated  by  a  depression  between  the  muscle  fibers  at  the 
point  of  impact,  or  there  may  be  tumefaction  indicating  hematoma. 
Nausea  and  vomiting  are  common  with  falling  or  rising  temperature. 
Shock  is  not  an  infrequent  symptom,  and  when  the  blow  is  delivered 
in  the  neighborhood  of  the  solar  plexus,  as  on  the  belt  buckle  from  a 
spent  ball,  the  shock  has  been  so  great  in  some  recorded  cases  as  to 
cause  prolonged  insensibility,  and  death.  ^ 

Contusion  with  rupture  of  viscera  is  rare  from  gunshot.  Otis 
reports  forty-one  cases  from  our  Civil  War  with  twenty  deaths. 
Among  these  were  one  rupture  of  the  liver,  and  one  of  the  spleen,  three 
of  the  kidney,  five  of  the. intestines  and  thirty-one  ruptures  of  viscera 
undetermined. 

In  recent  wars  contusions  of  the  abdominal  wall  alone  and  contu- 
sion attended  with  rupture  of  viscera  have  not  been  of  frequent  occur- 
rence. They  are  not  referred  to  by  Makins  in  his  Surgical  Experi- 
ences in  South  Africa,  while  Stevenson  refers  to  fourteen  cases  from 
various  kinds  of  missiles.  A  case  by  Sir  Watson  Cheyne  in  the  Anglo- 
Boer  War  and  quoted  by  Stevenson  is  one  of  the  most  remarkable  of 
any  contusion  of  the  abdomen  with  visceral  injury.  "A  man  was  shot 
1  inch  above  the  umbilicus  by  a  rifle-bullet  which  either  was  travelling 
at  such  low  velocity  or  grazed  the  abdominal  wall  so  obliquely  that  it 
only  removed  the  cuticle  over  an  area  of  1  inch  by  1/4  inch,  leaving 
apparently  the  true  skin  uninjured.  The  man  died  on  the  third  day 
from  peritonitis,  and  at  the  post  -mortem  two  lacerations  of  consider- 
able size  were  found  in  the  ilium,  immediately  beneath  the  site  of 
contusion.  The  specimen,  skin  and  intestine,  is  now  in  the  R.,  A. 
Museum."  In  our  opinion  such  an  occurrence  more  than  likely  took 
place  by  the  impact  of  a  spent  bullet  against  the  abdomen  when  the 
intestines  were  very  much  distended  with  gas  or  fluid  contents,  more 
than  likely  the  latter.  A  knuckle  of  intestine  pressing  against  the 
1  Delorme,  op.  cit.,  Vol.  II,  p.  746-7. 


228  GUNSHOT    WOUNDS 

wall  at  the  point  of  impact  no  doubt  received  enough  of  the  remaining 
energy  of  the  bullet  to  cause  rupture. 

In  the  Russo-Japanese  War  Graf  and  Hildebrandt^  state  that  con- 
tusion "with  rupture  was  rare  and  contracted  mostly  when  the  men 
were  lying  prone,  from  well-spent  balls.  When  the  official  reports 
of  the  great  war  in  Manchuria  have  been  published  we  will  no  doubt 
be  better  able  to  discuss  the  frequency  of  contusion  of  the  abdominal 
wall  by  the  new  armament  with  and  without  visceral  injury. 

Symptoms  of  contusion  of  the  abdomen  with  rupture  of  viscera 
are  quite  similar  to  those  of  contusion  of  the  abdominal  wall,  but  in 
addition  there  are  symptoms  of  a  serious  and  persistent  kind  which 
refer  to  internal  hemorrhage,  lesion  of  the  intestine,  or  rupture  of 
solid  viscera  like  the  kidney,  liver,  spleen,  etc.  The  symptoms  are 
not  always  definite  in  the  earlier  part  of  the  clinical  history. 

In  the  less  severe  cases,  viz.,  those  that  live  long  enough  for  the 
development  of  symptoms,  there  appears  in  addition  to  the  earlier 
symptoms  of  shock,  pain,  vomiting  and  rigidity  of  the  abdominal  wall, 
some  later  symptoms  which  point  to  hemorrhage  or  peritonitis.  The 
significance  of  these  symptoms  should  not  be  overlooked  because 
they  bear  on  the  extent  and  kind  of  injury,  and  because  they  are 
of  much  value  in  the  subsequent  treatment.  In  the  presence  of 
internal  hemorrhage,  the  patient  becomes  pulselessand  very  restless; 
pallor  and  difficult  breathing  appear  and  the  peritoneal  cavity  fills 
with  blood  as  evidenced  by  dullness  in  the  flanks.  The  dullness  will 
vary  as  it  does  when  present  in  other  cavities,  by  varying  the  position 
of  the  patient.  Retention  of  urine  is  a  frequent  symptom  in  the 
presence  of  hemorrhage.  The  source  of  hemorrhage  may  be  rupture 
of  one  of  the  solid  organs,  a  blood-vessel,  or  the  intestine;  but  most 
generally  it  results  from  fracture  of  the  liver  or  spleen.  Peritonitis 
usually  follows  rupture  of  some  part  of  the  intestinal  tract.  In  such  a 
case,  the  pre-existing  tenderness,  pain,  rigidity  and  vomiting  become 
more  intensified,  and  tympanites  becomes  more  marked. 

The  diagnosis  of  internal  injury  should  be  based  upon  a  survey  of 
the  symptoms.  In  some  cases,  the  symptoms,  at  first,  are  more  or 
less  misleading  since  they  are  in  no  wise  in  keeping  with  the  severity 
of  the  injury;  and  again,  a  marked  lesion  is  not  always  accompanied 
by  profound  shock,  or  other  symptoms  of  a  grave  injury.  For  instance 
sMght  contusion  of  the  abdominal  wall  has  been  known  to  coexist 
with  severe  shock,  or  the  symptoms  may  be  trivial  in  the  beginning, 

1  Op.  cit. 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  229 

when  extensive  lesion  is  present.  The  persistence  of  the  symptoms  is 
far  more  significant  than  their  severity.  In  a  case  of  rapid  pulse,  and 
persistent  vomiting,  with  increasing  rigidity  of  the  abdominal  wall, 
peritonitis  from  intestinal  rupture  is  almost  certain  to  be  present. 

Treatment. — In  simple  contusion  of  the  abdominal  wall  the 
treatment  is  purely  expectant.  Shock  if  present  is  treated  in  the 
usual  way.  The  patient  should  be  placed  in  bed  with  shoulders  ele- 
vated and  knees  drawn  up  to  relax  the  abdominal  muscles.  Morphia 
for  the  relief  of  pain  should  be  withheld  as  long  as  possible  since  its 
effects  are  prone  to  mask  some  of  the  important  symptoms  of  visceral 
lesion  when  present.  In  the  first  twenty-four  hours  it  is  better  to 
depend  upon  position  and  fomentations.  If  opium  is  to  be  used  in 
any  form  it  should  be  administered  as  morphine  hypodermatically. 

When  the  primary  symptoms  of  shock,  pain,  nausea  and  vomiting 
persist,  or  if  dullness  indicates  the  presence  of  blood  in  the  abdominal 
cavity,  the  abdomen  should  be  opened  at  once.  The  sooner  this  is 
done  after  a  reasonable  diagnosis  has  been  made  the  better  will  be  the 
chances  of  saving  life.  Cases  of  visceral  injury  from  contusion  when 
let  alone  all  die;  they  are  more  fatal  than  penetrating  wounds  by  the 
new  armament,  as  we  will  show  later  on.  For  this  reason  unfavorable 
environment  and  fear  of  setting  up  sepsis  by  opening  the  abdomen 
in  field  hospitals  should  form  no  excuse  for  delaying  operation.  A  man 
dying  of  internal  hemorrhage  has  only  one  chance  for  life  and  that  lies 
in  a  laparotomy.  Laparotomy  for  impending  peritonitis  from  rupture 
of  a  hollow  viscus  is  just  as  imperative.  As  soon  as  rupture  of  any  part 
of  the  intestinal  tract  becomes  known  or  strongly  suspected  by  the 
persistence  of  symptoms  of  tympanites,  rigidity  of  the  abdominal 
muscles,  and  rapid  pulse,  the  abdomen  should  be  opened  and  the 
ruptures  properly  sutured,  the  peritoneum  cleansed  of  blood  clots  and 
fecal  matter.  Shock  should  be  combated  with  appropriate  remedies 
including  hot  salt  solution  in  the  abdominal  cavity.  The  operation 
should  not  be  prolonged  any  more  than  is  absolutely  necessary.  The 
abdominal  incision  should  be  brought  together  by  interrupted  silk- 
worm gut  to  include  all  layers. 

(2)  Non-penetrating  Wounds  or  the  Abdomen. — The  chief  in- 
terest in  this  class  of  wounds  lies  in  the  dijEficulty  which  the  surgeon 
often  encounters  in  differentiating  non-penetrating  from  penetrating 
wounds.  Thanks  to  modern  methods  of  treatment  there  is  now  no 
mortality  attending  non-penetrating  wounds  of  the  abdomen,  since 
they   are    classed   with    simple   flesh   wounds.     Of    sixty-four    cases 


230  GUNSHOT   WOUNDS 

reported  by  the  Surgeon-General  of  the  U.  S.  Army  during  the 
Spanish-American  War  and  Philippine  Insurrection  there  was  no 
death,  while  the  death  rate  in  8612  recorded  cases  in  our  Civil  War  and 
the  Franco-German  War,  taken  together,  give  an  average  mortality 
of  8.3  per  cent. 

Non-penetrating  wounds  of  the  abdomen  are  less  frequent  with 
the  use  of  the  new  armament  because  of  the  greater  penetration  of 
the  new  military  rifle  buhet.  They  often  present  difficulty  in  diagnosis. 
The  gutter  wounds,  and  those  with  superficial  tracts,  indicate  very 
definitely  the  non-penetrating  character  of  the  wounds.  In  the  case 
of  a  lodged  ball  its  position  is  easily  defined  by  palpation  or  by  the 
X-ray.  The  greatest  difficulty  as  pointed  out  by  Mr.  Makins  was 
found  in  those  wounded  in  "the  thicker  muscular  portions  of  the 
lower  part  of  the  abdominal  and  pelvic  walls."  Wounds  of  the  colon 
and  sigmoid  fiexure  so  often  give  no  symptoms  that  penetration  of 
them  is  frequently  undetected. 

Treament. — Non-penetrating  wounds  of  all  kinds  are  treated  on 
the  principles  laid  down  for  infected  wounds.  They  should  be  cleansed 
of  shreds  of  clothing  and  foreign  matter  when  lacerated  and  when  the 
parts  of  the  wound  are  easily  accessible.  In  the  case  of  shots  trav- 
elling immediately  under  the  skin  for  any  distance  it  is  well  to  estab- 
lish drainage  at  different  points  or  to  lay  the  channel  open  and  treat 
the  wound  from  the  point  of  entrance  to  that  of  exit  as  an  open 
wound.  Missiles  when  properly  located  should  be  removed.  Splin- 
ters from  grenades  are  said  to  cause  extensive  multiple  wounds  which 
heal  slowly  on  account  of  loss  of  muscular  and  other  tissues. 

(3)  Penetrating  Gunshot  Wounds  of  the  Abdominal  Cavity. — 
Under  this  designation  we  include  those  gunshot  injuries  which 
penetrate  the  peritoneal  cavity  without  injury  to  either  the  omentum, 
mesentery  or  other  viscera.  Although  this  classification  is  adhered 
to,  we  recognize  that  so-called  penetrating  wounds  often  include 
injury  to  the  omentum  and  mesentery.  This  is  no  doubt  in  part 
the  class  of  wounds  that  has  recently  come  forth  in  sufficient  numbers 
to  puzzle  military  surgeons,  and  a  host  of  civil  surgeons  who,  for 
love  of  country,  and  a  desire  to  ameliorate  suffering,  have  rendered 
valuable  service  with  armies  in  recent  wars.  The  wounds  referred 
to  penetrate  the  intestinal  area,  but  they  give  no  special  indication  of 
visceral  injury,  and  they  often  or  nearly  always  recover.  The  idea 
that  a  projectile  is  capable  of  penetrating  the  peritoneal  cavity 
without  injury  to  the  viscera  is  not  new.     It  is  mentioned  by  the 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN  231 

older  writers,  who  under  their  expectant  plan  of  treatment  had 
reasons  to  suspect  such  an  occurrence  in  patients  that  recovered. 
Otis  mentions  such  cases,  and  one  in  particular  which  was  verified 
by  post-mortem,  in  a  soldier  who  died  from  injury  to  parts  outside 
the  peritoneal  cavity  as  follows:  "A  round  musket  ball  entered  the 
left  ninth  intercostal  space;  point  of  lodgement,  bod}^  of  second 
lumbar  vertebra.  The  bullet  traversed  the  chest,  perforating  the 
lung  and  diaphragm,  it  grazed  the  stomach,  colon  and  coils  of  jejunum. 
The  soldier  survived  three  weeks.  At  post-mortem  no  evidence  of 
peritonitis  was  present.  Death  was  due  to  lung  complications  and 
hectic  from  a  psoas  abscess."  In  another  case  the  ball  passed  obliquely 
across  the  abdominal  cavity  through  the  convolutions  of  the  small  intes- 
tines "  without  apparent  injury  to  any  portion  of  the  digestive  tube." 

The  Kaiserliche  Sanitats  Bericht,  1870-71,  gives  strong  presump- 
tive evidence  of  the  existence  of  this  class  of  wounds  by  the  larger- 
caliber  military  rifles.  Of  1534  gunshot  wounds  of  the  abdomen 
involving  the  peritoneal  cavity  thirty-three  are  reported  to  have 
been  wounds  of  the  peritoneum  alone  and  in  nine  of  these  the  bullet 
penetrated  the  abdomen  transversely  without  injur}^  to  the  intestines. 
The  surgeons  in  civil  practice  have  frequently  noted  such  cases  from 
the  effects  of  low  velocity  missiles  from  pistols  and  revolvers. 

After  the  introduction  of  the  reduced-caliber  rifles  it  was  thought 
that  injury  to  the  peritoneum  alone  might  be  less  frequently  observed 
because  of  the  superior  velocity  of  the  new  bullet,  which  causes  it 
to  cut  like  a  knife,  but  the  large  number  of  recoveries  in  recent  cam- 
paigns tends  to  negative  this  view.  Peritoneal  wounds  seem  to  be 
mostly  confined  to  shots  about  the  regions  of  the  jejunum,  ilium  and 
transverse  colon,  and  not  so  often  to  shots  over  the  stomach,  duodenum, 
the  ascending  and  descending  colons.  Shots  over  the  latter, 
and  the  solid  viscera,  are  more  readily  suspected  of  inflicting  perfora- 
tion, because  of  the  fixed  position  of  the  organs. 

At  Santiago  we  saw  men  who  had  recovered  from  abdominal 
wounds  by  the  Spanish  Mauser  bullet  when  the  track  of  the  bullet, 
as  judged  by  the  location  of  the  wounds  of  entrance  and  exit,  made  it 
impossible  for  the  bullet  to  have  travelled  outside  of  the  intestinal 
area*.  These  shots  were  mostly  disposed  antero-posteriorly,  but  in 
one  case  in  particular  the  shot  traversed  the  abdomen  obliquely  from 
one  flank  to  the  other.  The  patient  recovered  without  evidence 
of  either  general  or  local  peritonitis,  much  to  the  surprise  of  the 
surgeons  who  saw  the  case. 

16 


232 


GUNSNDSHOT    WOUNDS 


Various  explanations  have  been  given  to  account  for  these  bene- 
ficent effects  of  the  new  bullet.  One  is  that  the  small  intestine  is 
suspended  by  the  mesentery  in  a  way  to  permit  free  movement,  and 
as  the  coils  of  gut  are  superimposed  when  the  bullet's  track  takes 
certain  directions,  the  missile  is  able  to  travel  parallel  to  the  long  axis 
of  the  coils  without  perforation. 

One  of  the  most  indubitable  instances  of  gunshot  penetration  of 
the  abdomen  which  goes  far  to  support  the  contention  that  the 
movable  intestine  is  capable  of  being  pushed  aside  to  avoid  perforation 


Fig.   119. — Shows  the  denuded  and  lacerated  intestine  in  Thornburg  case. 


occurred  in  the  practice  of  Major  R.  W.  Thornburg,  U.  S.  A.,  as 
follows:  ''Private  William  Ummack,  Co.  "R",  30th  U.  S.  Infantry, 
recently  entered  Latterman  General  Hospital,  San  Francisco,  Cal., 
for  gunshot  wound  of  the  abdomen  self  inflicted.  The  weapon  used 
was  the  U.  S.  Army  reduced-caliber  magazine  rifle  loaded  with  a  full- 
charge   cartridge.     Wound  entrance   3X2   cm.    diameter,   located   5 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN 


233 


cm.  to  left  and  2  cm.  above  the  umbilicus.  Wound  of  exit  1  cm.  in 
diameter,  located  directly  above  left  posterior  superior  spine  ilium, 
on  a  level  with  umbilicus.  There  were  fifteen  wounds  of  ilium,  three 
of  descending  colon,  numerous  wounds  of  mesentery.  No  complete 
intestinal  perforation  discovered.  Twelve  ruptured  blood-vessels 
found.  Intestinal  wounds  consisted  of  destruction  of  peritoneum 
and  muscular  coats.  Wounds  of  viscera  principally  due  to  explosive 
effect  of  cone  of  fire  proceeding  base  forward^.    Muzzle  of  rifle  was 


Fig.   120. — Shows  omentum  covering  lesion  in  wound  of  mesentery  in  Thornburg  case. 

placed  against  body,  olive  drab  woolen  shirt  and  cotton  undershirt 
perforated  by  bullet. 

When  received  at  hospital  patient  was  so  much  shocked  that  the 
surgeons  refrained  from  doing  a  resection  of  the  wounded  intestine. 
The  wounds  of  the  colon  were  inverted,  blood-vessels  tied,  and  the 
wounded  ilium  and  mesentery  were  covered  by  omentum  as  shown 
in  Figs.  120,  121.  Fig.  122  shows  the  protruding  gut  and  a  piece  of 
omentum.     Fig.  119  depicts  the  character  of  the  lesion  of  the  denuded 


234 


GUNSHOT   WOUNDS 


and  lacerated  intestine.  The  patient  was  drained  front  and  rear 
and  placed  in  Fowler's  position  with  Murphy  drip  for  twenty-four 
hours.  There  was  at  no  time  any  infection  and  a  perfectly  normal 
convalescence  and  recovery  were  the  result." 

It  is  difficult  to  conceive  how  the  ball  and  the  explosive  charge 
could  have  traversed  the  abdominal  cavity  as  indicated  in  the  history 
of  this  case  without  perforating  the  intestinal  tube  except  upon  the 


Fig.   121. — Shows  omentum  covering  lesion  in  wound  of  mesentery  in  Thornburg  case. 

theory  of  displacement  by  the  pressure  which  was  exerted  upon  the 
tissues  in  all  directions.  That  the  intestinal  area  can  be  traversed 
by  a  rifle  bullet  without  opening  the  small  intestine  seems  also  to  have 
been  demonstrated  to  the  satisfaction  of  the  staff  of  A  Civilian  War 
Hospital.  The  authors  quote  the  case  of  Mr.  Lenthal  Cheatle  as  fol- 
lows: "A  private  was  shot  right  across  the  abdomen  in  a  fight  to  the 
west  of  Pretoria,  and  died  forty-eight  hours  later.  The  bullet  had  entered 
low  down  in  his  right  lumbar  region,  and  had  emerged  near  the  left 
anterior  superior  spine  of  the  ilium,  where  it  finally  lodged,  after  pass- 


GUNSHOT   WOUNDS    OF    THE   ABDOMEN 


235 


ing  through  the  skm  for  half  its  length;  it  was  a  ''Jeffreys  sporting 
bullet."  The  post-mortem  examination  showed  that  the  projectile 
had  passed  through  the  cecum  transversely,  close  to  its  posterior  wall, 
and  had  passed  out  through  the  sigmoid  flexure,  in  which  it  made  a 
large  rent.  It  was  thus  clear  that  the  bullet  had  passed  right  across 
the  cavity  of  the  abdomen,  and,  having  entered  it  posteriorly  and 
passed  from  behind  forward,  it  had  thus  traversed  the  abdomen  in  its 
antero-posterior  diameter  as  well.  In  spite  of  this,  however,  the  coils 
of  small  intestines  showed  no  wound  or  abrasion,  although  there  was 


Fig.   122. — Knuckle  of  gut  from  wound  of  entrance  and  omentum  from  wound  of  exit  in  Thornburg 

case. 


a  most  careful  search  after  removing  the  bowels  from  the  body. 
Other  cases  might  be  quoted,  but  this  one  is  enough  to  establish  be- 
yond doubt  the  possibility  of  a  bullet  traversing  the  abdominal  cavity 
below  the  umbilicus  without  wounding  the  small  intestine." 

From  the  foregoing  it  may  be  taken  for  granted  that  when  a  bullet 
traverses  the  intestinal  area  without  the  appearance  of  symptoms  of 
peritonitis  the  small  intestine  has  escaped  perforation. 


236  GUNSHOT   WOUNDS 

(4)  Perforating  Gunshot  Wounds  of  the  Abdomen. — In  this  class 
of  wounds  the  peritoneum  is  not  only  opened  but  there  is  lesion  of 
some  of  the  contained  viscera. 

Pathology. — The  wound  of  entrance  is  more  often  located  on  the 
anterior  surface  of  the  abdomen  and  this  is  especially  true  of  wounds 
met  in  civil  hospitals  from  personal  combat.  Less  often  the  wound 
of  entrance  is  located  on  the  flank  or  back.  In  military  practice  a 
projectile  often  enters  the  peritoneum  after  traversing  distant  ana- 
tomical parts.  Bullets  from  high-power  military  rifles  frequently 
enter  the  buttock,  neck  or  thorax,  and  subsequently  cause  perforating 
abdominal  wounds. 

Protrusion  of  the  omentum  or  intestine  is  common  from  shell 
wounds  and  the  wounds  of  the  military  rifle  at  proximal  ranges.  Pro" 
trusions  are  apt  to  occur  also  from  the  larger  calibers;  they  rarely  occur 
as  a  result  of  wounds  from  the  present-day  military  bullets  at  the 
battle  ranges. 

Referring  to  the  order  of  frequency  of  wounds  of  the  abdominal 
contents,  the  small  intestines  which  occupy  most  of  the  target  area 
rank  first,  next  in  frequency  come  the  liver,  stomach,  large  intestine, 
kidneys,  spleen,  and  pancreas. 

The  "Deutsche  Kriege  Sanitats  Bericht  found  in  192  cases: 

93  injuries  to  the  intestine, 48.43+  per  cent. 

68  injuries  to  the  hver, 35 .  41  + 

16  injuries  to  the  stomach, 8 .  33  + 

2  injuries  to  the  spleen, 1 .  04  + 

13  injuries  to  the  other  organs, 6 .  77  + 

Stevenson  found  in  161  cases: 

40     injuries  to  the  colon, 24.84+  per  cent. 

35     injuries  to  the  small  intestines, 21 .  73  + 

28     injuries  to  the  liver, 17.39  + 

17  injuries  to  the  bladder, 10. 55  + 

14  injuries  to  the  spleen, 8 .  69  + 

13     injiu-ies  to  the  stomach, 8.07  + 

13     injuries  to  the  rectum, 8 .  07  + 

1     injury  to  the  pancreas, 62  + 

The  American  Sanitary  Report  found  among  1092  cases: 

673  injuries  to  the  intestines, 61 .  63+  per  cent, 

173  injuries  to  the  liver, 15 .  84  + 

79  injuries  to  the  stomach, 7 .  23  + 

79  injuries  to  the  kidney, 7 .  23  + 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN  237 

54     injuries  to  the  blood-vessels  and  peritoneum, 4 .  94  + 

29     injuries  to  the  spleen, 2 .  65  + 

5     injuries  to  the  pancreas, 45  + 

Bullets  from  military  rifles  travel  in  a  straight  line  from  the  point  of 
impact  to  the  point  of  exit  or  lodgement,  and  the  organs  located  in  the 
bullets  path  are  usually  perforated.  In  civil  practice,  and  in  the  days 
of  low-velocity  weapons,  balls  were  known  to  pursue  an  erratic  course. 
The  literature  on  the  subject  of  glancing  balls  from  the  resistance  en- 
countered in  fascia,  tissues  like  bone,  tendons,  etc.,  appears  incredible 
to  us  to-day,  and  such  occurrences  are  no  longer  considered  possible 
with  the  use  of  the  more  perfect  modern  firearms.  The  surgeon  is 
therefore  justified  in  estimating  the  lesion  in  a  given  case  to  include 
the  structures  in  the  path  of  the  bullet  as  determined  by  the  location 
of  the  apertures.  This  statement  contemplates  due  consideration 
of  the  position  of  the  individual  at  the  time  of  injury. 

The  character  of  the  lesion  in  the  abdomen  largely  depends  on  the 
factors  of  velocity,  sectional  area  and  resistance  on  impact.  The 
latter  is  especially  variable  in  this  anatomical  region,  depending  as  it 
does  on  the  amount  of  fluid  contained  in  the  intestinal  tube  when  hit. 
As  already  pointed  out  in  preceding  chapters,  there  are  two  things  in 
the  body  which  offer  maximum  resistance  to  the  bullet,  viz.,  compact 
bone  and  water.  The  degree  of  traumatism  in  muscle  tissue  at  a 
5-foot  range,  for  instance,  for  the  present  service  rifle  is  not  much 
beyond  17  mm.  If,  however,  the  ball  should  make  an  impact  at  the 
same  range  upon  the  intestine  or  stomach  when  these  organs  are  loaded 
with  fluid  contents,  the  resistance  encountered  by  the  maximum 
velocity  would  result  in  extensive  lacerations  and  shock,  which  would 
end  in  death  at  once  or  very  soon  thereafter.  If  the  intestine  is  but 
partially  loaded  the  lesion  will  be  correspondingly  less,  and  if  it  lies 
empty  the  amount  of  destruction  will  be  no  less  than  we  find  in  other 
soft  parts,  like  muscle  tissue.  In  the  case  of  the  latter  the  amount  of 
destructive  effects  would  be  measured  more  by  the  sectional  area  of 
the  bullet.  Wounds  from  a  .45-caliber  bullet  as  an  example  would  be 
correspondingly  more  lacerated  and  contused  than  those  from  a  .22- 
caliber  Flobert  rifle,  or  the  projectile  of  the  reduced-caliber  rifle. 

The  size  and  character  of  the  wound  in  a  hollow  viscus  si  also 
influenced  by  the  angle  of  impact.  Wounds  from  shots  transverse  to 
the  gut  are  smaller  than  those  disposed  in  an  oblique  direction.  The 
redundance  of  the  mucous  membrane  over  the  serous  coat  also  influ- 
ences the  size  of  the  opening  and  liability  to  escape  of  gas  and  fluid 


238  GUNSHOT   WOUNDS 

contents  in  the  peritoneal  cavity.  Perforation  of  the  small  intestine 
is  followed  by  eversion  of  the  edge  of  the  mucous  coat  and  in  small 
perforations  like  those  of  the  .30-caliber  military  rifle,  this  occurrence 
may  go  far  to  explain  the  unexpected  recoveries  that  have  become  so 
common  in  recent  campaigns.  This  hernia  which  is  said  to  be  due 
to  the  redundance  of  the  mucous  coat  and  further  to  contraction  of  the 
circular  muscular  fibers  is  not  so  apt  to  occur  in  wounds  of  the  stomach 
or  colon. 

Wounds  of  the  intestines  per  se  are  not  prone  to  hemorrhage  unless 
the  lesion  is  located  at  the  mesenteric  border.  On  the  other  hand 
wounds  of  the  mesentery  proper,  the  omentum,  and  solid  viscera  are 
very  apt  to  be  followed  by  bleeding.  The  cutting  effects  of  reduced- 
caliber  jacketed  bullets  are  specially  exhibited  in  injury  to  vessels  in 
the  abdomen  and  doubtless  this  class  of  wounds  figures  quite  a  bit  in 
swelling  the  mortality  list  on  the  field  in  the  wars  of  to-day.  Hemor- 
rhage on  the  whole  is  one  of  the  most  frequent  causes  of  death  in 
abdominal  wounds.  Its  occurrence  is  aggravated  by  the  engorgement 
of  the  internal  organs  when  reaction  from  shock  is  about  to  take  place. 

Extravasation  from  the  stomach,  the  urinary  and  gall  bladders 
has  an  important  pathological  significance.  Wounds  of  the  latter 
two  are  usually  followed  by  discharge  of  their  entire  contents  while 
a  wound  of  the  stomach  is  only  accompanied  by  partial  extravasation 
when  the  wound  is  sufficiently  large. 

Extravasation  takes  place  immediately  when  the  wound  is  manipu- 
lated and  if  the  opening  happens  to  be  large.  Even  in  extensive 
wounds  Douglas^  states  that  extravasation  occurs  less  frequently  in 
the  first  few  hours  than  is  generally  supposed.  Eversion  of  the  mucous 
membrane  and  arrest  of  peristalsis  during  the  first  twenty-four  hours 
are  chiefly  concerned  in  preventing  extravasation.  Should  peristalsis 
be  resumed  the  mucous  membrane  is  retracted,  and  if  the  exudate  is 
insufficient  extravasation  takes  place. 

Wounds  of  the  mesentery  find  their  chief  pathologic  interest  when 
the  projectile  cuts  a  vessel.  Hemorrhage  threatening  life  at  once,  or 
gangrene  later,  is  the  chief  danger.  The  latter  is  especially  prone  to 
occur  in  wounds  at  the  mesenteric  border. 

The  facts  to  be  remembered  when  in  the  presence  of  a  gunshot 
wound  of  the  abdomen  are : 

(1)  The  outcome  is  problematical. 

(2)  The  exact  lesion  is  uncertain. 
1  Op.  cit. 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  239 

(3)  All  wounds  are  septic  from  (a)  the  clothing,  (b)  skin,  (c)  the 
projectile  and  (d)  extravasation  when  present. 

(4)  Complications  are  uncertain. 

(5)  When  the  abdominal  cavity  has  been  penetrated,  visceral 
perforations  are  present  in  97  per  cent,  of  the  cases. 

(6)  A  bullet  crossing  the  intestinal  area  may  do  so  without  perfor- 
ating the  gut,  but  the  occurrence  of  perforations  is  the  rule.  As 
many  as  twenty-eight  perforations  have  been  recorded  in  one  case. 
Multiple  perforations  occur  mostly  in  the  ilium  from  transverse  and 
oblique  shots  disposed  from  flank  to  flank. 

The  outcome  will  depend  upon  the  nature  of  the  injury,  the 
amount  of  hemorrhage,  the  character  of  infection  and  the  presence 
of  extravasation  from  the  intestinal  track,  the  biliary  and  urinary 
passages.  A  small  hemorrhage  may  be  absorbed,  large  hemor- 
rhages unless  they  prove  immediately  fatal  are  prone  to  undergo 
septic  changes  ending  in  peritonitis.  Effused  blood  is  at  times  walled 
off  by  plastic  lymph  and  then  absorbed,  otherwise  pus  formation  takes 
place.  The  development  of  perforation  peritonitis  in  cases  of  intes- 
tinal perforation  is  the  rule  in  the  course  of  twelve  to  twenty-four 
hours.  Virulent  infections  have  been  known  to  cause  death  before 
the  appearance  of  the  characteristic  changes  incident  to  peritonitis. 

General  Symptoms. — Constitutional  shock  is  the  first  symptom  to 
attract  attention.  It  is  not  always  present,  however,  and  it  may  be 
present  in  profound  degree  in  cases  where  the  peritoneum  has  not 
been  involved,  a  fact  which  tends  to  lessen  its  importance  as  a  symp- 
tom with  diagnostic  features.  It  is  generally  admitted  that  the 
importance  of  shock  as  a  symptom  rests  on  its  duration. 

Vomiting  is  a  pretty  constant  attendant  symptom  of  penetrating 
wounds  of  the  abdomen,  but  it  may  be  due  to  shock  as  well.  Vomit- 
ing of  blood  is  indicative  of  gastric  perforation  but  not  necessarily 
so.     It  may  occur  from  contusion. 

Pain  at  first  of  a  colicky  and  griping  nature  about  the  region  of 
the  umbilicus  is  a  fairly  constant  symptom  of  lesion  of  the  small  in- 
testine (Parker  and  Myer) .  Later  the  pain  radiates  to  the  chest  and 
groins  and  generally  over  the  abdomen. 

Tympany  occurring  suddenly  from  escape  of  intestinal  gases 
sufficient  to  efface  liver  and  splenic  dullness  was  evidently  common 
with  the  use  of  larger-caliber  bullets  because  Otis  refers  to  it  as  one 
of  the  important  symptoms.  The  use  of  smaller  calibers  and  the  sub- 
sequent hernia  of  the  mucosa  in  the  small  opening  has  the  tendency 


240  GUNSHOT   WOUNDS 

to  prevent  the  escape  of  gas  because  Treves  and  other  observers  in 
recent  times  lay  no  stress  upon  it  as  a  sign  of  diagnostic  value.  It  is 
a  prominent  symptom  of  intestinal  perforation  in  later  complications 
and  perforations. 

Emphysema  occuring  in  the  cellular  tissue  about  the  wound  is  a 
rare  symptom.  It  is  not  a  definite  sign  of  intestinal  perforation 
although  it  does  occur  after  wounds  of  the  colon  from  colon  bacillus 
infection. 

There  are  certain  signs  which  are  regarded  as  positive  evidence 
of  intestinal  perforation: 

(1)  Escape  of  intestinal  gas,  feces  or  intestinal  worms  from  the 
wound  of  entrance  or  exit. 

(2)  Protrusion  of  the  injured  gut  at  wound  of  entrance  or  exit. 

(3)  Passage  of  the  missile  or  blood  by  the  anus. 

Escape  of  gas  and  feces  and  protrusion  of  the  intestines  were  com- 
mon enough  symptoms  from  wounds  by  the  old  armament  and  they 
are  common  with  the  use  of  present-day  projectiles  when  the 
injury  exhibits  explosive  effects  or  from  wounds  inflicted  by  shell  frag- 
ments and  shrapnel.  Escape  of  intestinal  worms  is  rare,  except  among 
peoples  in  tropical  countries  where  intestinal  parasites  are  to  be  found 
in  the  intestines  of  all  natives.  Four  worms  were  found  making  their 
way  in  the  peritoneal  cavity  in  one  of  the  author's  cases  in  the  Philip- 
pines fourteen  hours  after  the  injury,  and  the  small  intestines  were 
everywhere  inhabited  by  the  ascaris  lumbricoides.  The  great  diffi- 
culty with  the  more  certain  signs  of  intestinal  lesion  lies  in  the  fact 
that  they  are  either  absent  or  late  in  making  their  appearance.  Pas- 
sage of  red  blood  from  the  anus  indicates  lesion  of  the  colon  or  rectum, 
but  as  stated  already  it  is  one  of  the  later  symptoms.  Dark  bloody 
stools  indicate  lesion  of  the  small  intestine.  Its  escape  from  the  anus 
is  in  the  form  of  a  dark  semifluid  mass  (melena) ,  but  it  does  not  appear 
until  re-establishment  of  peristalsis  which  occurs  too  late  to  make  the 
symptom  of  diagnostic  significance  to  the  surgeon. 

Diagnosis  of  perforation  has  often  to  be  inferred  from  a  study  of 
the  location  of  the  apertures  made  by  the  ball  and  the  various  anatomi- 
cal structures  which  normally  lie  in  the  bullet's  path.  In  the  days 
of  low-velocity  projectiles  much  was  written  of  the  erratic  course  of 
balls.  It  is  said  that  missiles  often  took  circuitous  routes  from  the 
point  of  entry  to  the  point  of  exit  on  impact  against  hard  and  soft 
tissues  ahke.  Much  of  this  sounds  like  fable  now.  As  we  understand 
the  mechanics  of  projectiles  to-day,  we  recognize  no  angles,  nor  devia- 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  241 

tions  to  occur  from  the  point  of  impact  to  that  of  exit.  We  regard 
the  idea  of  a  modern  bullet  deflected  dy  the  skin,  fascia,  or  a  knuckle 
of  intestine  as  mythical.  We  figure  that  everything  in  the  line  of 
flight  of  a  bullet  is  perforated  and  the  surgeon  who  relies  on  this  idea 
is  seldom  wrong. 

Doctor  Senn  once  advocated  the  so-called  hydrogen  gas  test  to 
detect  intestinal  perforation,  but  this  method  in  diagnosis  is  unreliable 
and  it  takes  valuable  time. 

The  cUagnosis  of  the  exact  lesion  is  not  so  important  as  the  diagnosis 
of  penetration  of  the  peritoneal  cavity  itself,  and  that  must  be  inferred 
from  the  position  of  the  wounds  and  the  direction  in  which  the  bullet 
was  travelling  at  the  moment  of  impact.  Whether  the  small  intestine 
is  injured  or  whether  it  is  the  large  intestine  does  not  matter.  It  is 
all  guess  work  at  best  until  the  abdomen  is  opened.  The  most  that 
we  can  say  is  that  wounds  in  the  umbilical  region  are  apt  to  be  attended 
with  lesion  of  the  small  intestine,  wounds  disposed  transversely  from 
flank  to  flank  are  apt  to  be  complicated  by  lesion  of  the  colon;  those 
located  above  a  line  drawn  across  the  umbilicus  and  below  the  costal 
margin  are  more  often  attended  with  lesion  of  the  transverse  colon 
and  stomach,  while  wounds  disposed  obliquely  may  implicate  large  and 
small  intestines  and  some  of  the  solid  viscera  as  well.  Escape  of  hard 
fecal  matter  from  the  external  wound  suggests  lesion  of  the  large  intes- 
tine and  if  the  fecal  matter  be  fluid  the  evidence  points  to  lesion  of  the 
small  intestine.  Dark  blood  in  the  stools  occurs  with  lesion  of  the 
small  intestine,  while  red  blood  indicates  lesion  to  the  large  gut. 

Prognosis  and  Fatality  of  Perforating  Gunshot  Wounds  of  the 
Abdomen. — The  gravity  of  this  class  of  wounds  ranks  with  that  of 
wounds  of  the  head  and  spine.  It  was  especially  so  with  the  use  of  the 
old  armament.  Penetrating  and  perforating  wounds  of  the  abdomen 
regardless  of  the  viscera  involved  gave  a  mortality  of  92.5  per  cent, 
in  the  Crimean  War;  90  per  cent,  in  our  great  Civil  War;  69  per  cent, 
in  the  Franco-German  War;  an  average  of  67.1  per  cent,  in  115 
cases  in  the  Spanish-American  War  and  Philippine  Insurrection; 
and  approximately  56  per  cent,  for  the  Russian  wounded  in  Manchuria. 

Shock  from  extensive  lesion  of  the  abdominal  contents  is  a  potent 
cause  of  death  on  the  field.  Impact  at  close  range  from  the  high- 
power  military  rifle  bullet,  especially  when  the  digestive  tube  is  filled 
with  semifiuicl  contents,  causes  wounds  with  explosive  effects  that 
prove  rapidly  fatal.  The  wounds  which  favor  hemorrhage  and  shock 
seldom  reach   field  or  base  hospitals,  they  are  uniformly  fatal  in  a 


242  GUNSHOT   WOUNDS 

very  few  hours,  and  they  occur  amid  environments  which  preclude 
laparotomy. 

At  the  same  time  that  the  reduced-caliber  bullet,  impressed  with 
maximum  energy,  proves  so  deadly  as  in  the  foregoing  class  of  cases, 
there  are  other  cases  occurring  at  mid  and  more  remote  ranges  which  live 
to  reach  field  hospitals  with  but  few  of  the  marked  symptoms  of  per- 
foration. The  large  majority  of  these  are  followed  later  by  the  sudden 
development  of  fatal  septic  peritonitis.  There  is  still  another  class 
in  which  the  location  of  the  wounds  points  strongly  to  the  presence  of 
visceral  lesion,  with  but  slight  symptoms  of  perforation.  These  cases 
are  apt  to  end  in  recovery  and  they  form  a  surprising  percentage  of 
the  cases  in  the  field  hospitals  of  recent  wars.  This  was  the  class  of 
cases  that  stood  out  as  a  puzzle  to  the  surgeons  of  the  5th  Army  Corps 
at  Santiago  who  were  among  the  first  to  recognize  the  divergence  that 
lies  in  the  jDathology,  prognosis,  and  the  necessity  for  surgical  inter- 
ference, between  cases  of  abdominal  wounds  in  military  and  civil 
hospitals. 

TREATMENT  OF  PENETRATING  AND  PERFORATING  GUN- 
SHOT WOUNDS  OF  THE  ABDOMEN 

Whether  the  contained  viscera  have  been  perforated  or  not  the 
treatment  of  gunshot  wound  of  the  abdomen  at  the  onset  is  the  same. 
This  may  be  divided  into  general  and  operative  measures.  The  gen- 
eral treatment  consists  in  absolute  rest  on  the  back  with  shoulders 
raised  and  the  knees  flexed.  The  latter  will  materially  add  to  the  com- 
fort of  the  patient.  Transport  for  any  distance  should  be  withheld. 
If  necessary  to  remove  the  patient,  even  on  a  stretcher,  this  should 
be  done  with  great  care.  The  patient  should  himself  remain  absolutely 
passive  in  any  effort  to  move  him.  All  fluids,  food  or  medicines  per 
OS  should  be  interdicted  for  thirty-six  to  forty-eight  hours.  Thirst 
may  be  relieved  by  injections  of  warm  water  per  rectum.  Shock  may 
be  combated  by  strychnia  hypodermically  and  stimulants  per  rectum. 
The  external  wounds  should  be  dressed  antiseptically.  For  cases 
occurring  on  the  field  painting  the  skin  about  the  wound  with  tincture 
of  iodine  preceding  the  application  of  a  first-aid  dressing  is  preferable. 

When  operation  is  not  to  be  practised,  opium  should  be  admin- 
istered in  the  form  of  morphine  hypodermically  to  control  pain  and 
peristalsis.  In  cases  which  lend  a  hope  of  recovery  opium  will  form 
the  sheet  anchor  of  the  treatment,  and  in  those  which  appear  hopeless 
it  will  amehorate  suffering. 


GUNSHOT   WOUNDS    OF   THE    ABDOMEN  243 

The  question  of  operation  has  received  much  attention  in  recent 
times  especially  from  surgeons  in  civil  practice.  Since  the  great 
advances  in  abdominal  surgery,  the  question  of  operation  in  military 
practice  was  never  prominently  brought  to  the  attention  of  military 
surgeons  until  the  Spanish-American  and  Anglo-Boer  Wars.  At  the 
same  time  that  it  was  the  rule  in  civil  hospitals  to  operate  in  all  cases 
as  early  as  possible,  the  U.  S.  Army  surgeons  were  among  the  first  to 
recognize  that  the  rule  of  our  civil  confreres  could  not  be  followed  in 
military  practice  and  this  view  has  since  been  accepted  by  military 
surgeons  in  all  countries.  Incidentally  the  failure  of  militar}^  surgeons 
to  follow  the  lead  of  men  in  civil  practice  has  enabled  the  profession 
to  observe  what  may  be  the  outcome  in  cases  that  are  let  alone,  and  as 
we  hope  to  show  later,  the  results  in  the  practice  of  military  surgeons 
in  recent  wars  have  had  their  influence  in  modifying  the  views  of  opera- 
tors in  civil  life. 

Surgeons  in  civil  practice  were  and  many  are  still  of  the  opinion 
that  early  laparotomy  with  a  view  to  exploration  and  the  performance 
of  such  surgical  attention  as  existing  lesion  might  demand  offer  the 
best  chance  for  recovery.  Their  conclusions  were  based  upon  statis- 
tics of  non-operated  cases  in  the  pre-operative  era  which  are  quoted 
in  all  of  the  literature  and  which  run  about  as  follows:  for  every  100 
cases  of  gunshot  perforation  of  the  abdomen  the  intestines  will  be  per- 
forated in  73.2  per  cent,  and  death  is  the  rule  in  all  cases.  Either  the 
intestines  or  solid  viscera  or  both  will  be  injured  in  99.8  per  cent,  of 
the  cases  and  for  these  death  is  the  rule  in  nearly  every  case  in  a  few 
days  or  weeks,  as  a  result  of  septic  infection  or  abscess.  If  these  sta- 
tistics are  correct  there  is  no  doubt  that  surgeons  of  skill  in  abdominal 
work,  under  favorable  environment  were,  and  still  are,  justifiable  in 
folloTsdng  the  rule  of  an  early  operation  in  all  cases. 

Doctor  W.  E.  Parker^  has  shown  that  when  cases  are  treated  by 
laparotomy,  those  exhibiting  wound  of  the  solid  viscera  give  a  mor- 
tality of  only  61.6  per  cent.,  while  of  the  class  involving  both  solid  and 
hollow  viscera  there  is  a  mortality  of  62  per.  cent.  Parker  f  m'ther  shows 
that  the  mortality  rate  rises  as  the  time  of  operation  is  delayed  and 
that  of  the  cases  showing  wound  of  the  hollow  viscera  operated  upon 
within  the  first  seven  hours  the  mortality  falls  as  low  as  47  per  cent. 
The  hope  of  recovery  in  those  operated  upon  between  seven  and  four- 
teen hours  declines  rapidly  and  all  hope  is  practically  lost  after  the 
lapse  of  twenty-four  hours. 

1  Proceedings  Southern  Surgical  and  Gynecological  Asso.,  Vol.  XI,  1896. 


244  GUNSHOT    WOUNDS 

Dr,  Ernest  SiegeP  points  out  that  the  death  rate  in  532  non-operated 
cases  was  55.2  per  cent.;  and  51.6  per  cent,  in  736  cases  subjected  to 
operation.  This  tabulation  was  made  in  1898  for  cases  occurring  from 
weapons  used  in  civil  life  prior  to  that  time.  The  results  favor  treat- 
ment by  operation  by  the  small  margin  of  3.6  per  cent.  For  those 
operated  upon  within  the  first  four  hours  the  mortality  is  only  15.2 
per  cent.,  while  of  those  operated  upon  after  twelve  hours  the  mortality 
is  70  per  cent. 

Fenner^  gives  a  series  of  105  cases  with  visceral  perforation  sub- 
jected to  operation  with  a  mortality  of  73.95  per  cent. 

Richard  Douglas^  collected  65  cases  operated  upon  in  the  literature 
between  1895  and  1900  not  included  in  Siegel's  cases,  with  the  surpris- 
ingly low  mortality  of  32.3  per  cent. 

In  the  Spanish-American  War  we  had  surgeons  of  recognized 
ability  from  civil  life  who  accompanied  the  army  at  the  front.  Among 
these  were  Professor  Nicholas  Senn  of  Chicago,  with  the  rank  of 
Lieutenant-Colonel  of  Volunteers,  Major  Charles  Nancrede,  U.  S. 
Volunteers,  Professor  of  Surgery  in  the  University  of  Michigan,  and 
Doctor  W.  E.  Parker,  Acting  Assistant  Surgeon,  U.  S.  A.,  of  New  Or- 
leans, just  referred  to.  Doctor  Parker's  impressions  of  gunshot 
wounds  of  the  abdomen  by  the  Spanish  Mauser  under  the  conditions 
that  obtain  in  active  campaign  are  set  forth  in  a  paper  read  before  the 
Southern  Surgical  and  Gynecological  Association  at  its  annual  meeting 
1898-99.  He  mentions  the  three  laparotomies  which  were  done  at 
the  front  with  fatal  results  and  cites  cases  in  which  he  had  the  oppor- 
tunity to  perform  laparotomy  himself  and  where  he  advised  against 
operation  because  of  "the  small  caliber  of  the  bullet,  the  difficulty  in 
getting  hot  water,  and  the  absence  of  trained  assistants.  Then,  too, 
it  is  a  good  deal  of  a  question  if,  in  the  congested  condition  of  an  army 
hospital  after  a  battle,  we  would  be  justified  in  taking  the  time  neces- 
sary for  such  an  operation  to  the  detriment  of  other  wounded  men." 
In  concluding  this  paper  he  advised  against  operative  interference  on 
the  field  except  in  the  presence  of  internal  hemorrhage.  After  Doctor 
Parker  had  read  a  paper  at  a  previous  meeting  in  1896  on  Penetrating 
Wounds  of  the  Abdomen,  before  the  same  Society,  a  lengthy  discussion 
took  place  on  the  management  of  gunshot  wounds  of  the  abdomen  in 

1  Siegel,  Beitrage  zur  klin.  Chirurg.,  XXV,  1898. 

2  Fenner.     Annals  of  Surgery,  Vol.  XXXV,  1902. 

^  Richard  Douglas,  Surg.  Diseases  of  the  Abdomen,  P.  Blakiston,  1909. 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN  245 

which  some  of  the  leading  surgeons  of  this  country  took  part.  The 
views  of  the  members  were  so  generally  unanimous  in  favor  of  early 
operation  that  the  Association  then  and  there  adopted  a  resolution 
which  proclaimed  it  to  be  the  sense  of  the  Southern  Surgical  and  Gyneco- 
logical Association  that  in  all  cases  of  penetrating  wounds  of  the  abdo- 
men it  became  the  duty  of  the  attending  surgeon  to  make  an  explora- 
tory incision.  aTid  that  wh^n  ioTmd  necessary  the  repair  of  existing 
lesions  should  be  practised.  This  was  the  doctrine  advocated  prior 
to  the  Spanish-American  War  by  surgeons  in  civil  life  generally. 
Naturall}'  when  Doctor  Parker  read  his  second  paper,  after  the  battle 
of  Santiago,  in  which  he  advocated  "that  abdominal  work  should  not 
be  attempted  in  the  field  unless  there  are  symptoms  of  hemorrhage," 
some  of  his  confreres  thought  that  he  had  receded  from  his  position  of 
three  years  before,  but  in  the  discussion  which  followed  the  reading 
of  this  paper,  he  took  occasion  again  to  express  his  former  convictions 
on  the  value  of  early  operation  in  civil  hospitals  in  which  he  stated 
that  laparotomy  was  the  first  thing  to  do. 

The  hesitancy  which  Doctor  Parker  and  all  our  surgeons  expressed 
at  the  battle  of  Santiago  toward  laparotomy  has  been  voiced  by  sur- 
geons in  recent  wars  generally.  Treves,  MacCormack,  Watson  Chey- 
ene,  Makins  and  Stevenson  in  the  Anglo-Boer  War  admit  the  value 
of  the  rule  to  open  the  abdomen  early  in  civil  practice,  but  they  are 
unanimous  in  advising  against  operation  in  active  campaign  because 
of  the  want  of  trained  assistants  and  the  unfavorable  conditions  that 
obtain  to  properly  secure  aseptic  work,  and  because  so  many  of  the 
cases  get  well  without  operation. 

Mr.  Makins,  writing  from  the  standpoint  of  a  civil  surgeon  upon 
cases  in  which  penetration  had  occurred  in  the  central  area  around  the 
umbilicus  in  the  South  African  campaign,  states  as  follows:  ''The 
surgeon  will  often  find  himself  surrounded  by  difficulties,  so  hand- 
tied  by  the  overcrowded  state  of  the  field  hospital  and  want  of  all  but 
the  most  inadequate  means  of  even  aseptic  work,  that  he  may  feel 
himself  compelled  to  refrain  from  interfering,  while  he  knows  that 
under  other  circumstances  operation  might  give  the  patient  a  chance 
of  life." 

As  to  the  experience  of  army  surgeons  in  the  Russo-Japanese  War, 
they  took  the  field  fully  advised  of  the  untoward  experience  of  the 
American  and  English  surgeons.  Nevertheless,  the  reports  show  that 
on  both  sides,  the  Russian  and  Japanese  surgeons  did  laparotomies  in 
the  beginning  of  the  campaign.     Major  Charles  Lynch,  Medical  Corps, 


246  GUNSHOT    WOUNDS 

U.  S.  A.,^  our  attache  with  the  Japanese  army,  states  that  abdominal 
wounds  were  universally  treated  on  the  expectant  plan  by  the  Japanese 
surgeons,  and  speaking  of  field  environments  he  says  ''it  would  have 
been  absolutely  unjustifiable,  however,  for  either  the  Russian  or  Japa- 
nese to  have  operated  with  the  conditions  as  they  existed."  In  the 
early  part  of  the  war  he  saw  laparotomies  performed  but  the  results 
were  so  discouraging  that  the  operating  surgeons  had  to  desist  in  the 
same  way  that  some  of  our  operators  were  commanded  to  desist  from 
operative  interference  on  the  line  at  Santiago. 

Follenfant,  a  French  Medical  Officer  with  the  Russian  army  saw 
some  successful  laparotomies  performed  in  a  specially  prepared  operat- 
ing room  on  a  hospital  train  inside  of  three  hours  after  the  injury, 
otherwise  the  success  attained  in  primary  laparotomies  was  bad.  He 
states  that  in  the  hospitals  at  the  rear,  partia'  laparotomies  for  the 
evacuation  of  abscesses  consequent  upon  localized  peritonitis  were 
frequently  performed  with  success.  To  us  this  is  additional  evidence 
of  the  number  of  cases  of  gunshot  wound  of  the  abdomen  by  the  new 
military  rifle  that  recover  without  fatal  septic  peritonitis.  As  a  matter 
of  fact  Follenfant  was  strongly  impressed  by  the  beneficence  which 
resulted  from  the  use  of  small-caliber  bullets  in  this  war.  He  saw  men 
who  were  cured  and  restored  to  duty  after  apparent  gunshot  lesion  of 
the  intestine,  without  operation.  But  he  adds  that  penetrating 
gun-shot  wounds  of  the  abdomen  by  shrapnel  balls  were  generally 
fatal. 

Another  of  our  attaches,  Col.  Valery  Havard,  Medical  Corps, 
U.  S.  A., 2  saw  twenty-five  cases  of  gunshot  injury  of  the  abdominal 
cavity.  ''No  operation  was  possible  or  attempted."  Some  of  the 
wounded  had  been  transported  forty  miles  in  carts  over  rough  roads, 
and  also  on  horseback.  Seven  died.  Eight  developed  peritonitis. 
These  happy  results  were  no  doubt  obtained  from  the  slightly  wounded 
• — -cases  in  which  the  viscera  were  but  slightly  injured,  where  the  hollow 
viscera  were  probably  not  perforated  and  if  perforated  the  nar- 
row perforation  was  more  than  likely  occluded  by  hernia  of  the 
mucosa. 

The  cases  reported  by  Bornhaupt,^  who  was  attached  to  a  Red 
Cross  Hospital  on  the  Russian  side  in  the  Manchurian  campaign,  give 

1  War  Department,  Office  General  Staff,  No.  3,  Jan.  1,  1907. 

2  War  Dept.  Report  Gen'l  Staff,  No.  3,  Oct.  1,  1906. 

^  G.  S.  W.  Abdomen,  Russo-Jap.  War  by  Leo  Bornhaupt,  Archiv.  fiir  Ivlinische 
Chirr.,  Part  LXXXIV. 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  247 

further  evidence  of  the  beneficence  which  results  from  gunshot  wounds 
of  the  abdomen  by  reduced  calibers.  It  should  be  remembered  that  the 
bullet  of  the  Japanese  was  the  smallest  in  caliber  of  the  modern  military 
rifle  projectiles,  being  6.5  mm.  weighing  about  157  grains.  He  states 
that  out  of  all  penetrating  shot  wounds  that  came  to  hospital  for  treat- 
ment 89.9  per  cent,  were  inflicted  by  the  jacketed  rifle  bullet.  Out 
of  162  penetrating  wounds  of  the  abdomen  three  were  caused  by 
baj^onet  thrusts,  sixteen  by  shrapnel  and  162  by  jacketed  bullets. 

Those  who  were  received  for  treatment  were  shot  generally  six 
or  eight  days  before,  only  a  few  receiving  more  than  first-aid  treatment 
on  the  hospital  trains  to  Karbine.  Out  of  162  cases,  138  showod 
both  wounds  of  entrance  and  exit;  in  twenty-four  or  fourteen  per  cent, 
the  bullet  lodged;  in  three  instances  the  patients  received  two  pene- 
trating wounds  of  the  abdomen.  He  divides  the  162  cases  into  four 
groups  of  which  the  first  three  required  no  operation,  the  treatment 
was  expectant.     The  fourth  group  required  operation. 

In  eighty-nine  cases  of  the  first  three  groups  there  were  no  symp- 
toms. Out  of  115  cases  treated  conservatively  but  three  died  giving 
a  mortality  of  2 . 6  per  cent. 

The  symptoms  in  the  early  part  of  the  history  of  the  cases  were 
gathered  from  statements  of  the  patients  themselves.  Some  showed 
signs  of  peritoneal  irritation — pains  in  the  abdomen,  vomiting  and  tym- 
panites. After  five  or  six  days  all  these  symptoms  disappeared.  Most 
of  them  walked  from  2  to  5  miles  to  the  dressing  station  where  a  first- 
aid  dressing  was  applied;  some  were  carried  by  comrades  and  some 
rode  on  horseback. 

In  four  of  the  cases  the  shots  were  delivered  at  very  close  range, 
while  the  remainder  received  the  wounds  at  30,  40,  50,  200  and  1600 
yards.  Some  of  the  shots  ran  transversely,  obliquely  and  antero- 
posteriorly  through  the  intestinal  area. 

In  all  great  battles  there  are  no  doubt,  with  the  use  of  the  present 
armament,  a  certain  number  of  abdominal  wounds  destined  for  a 
favorable  outcome,  in  the  same  way  that  a  larger  number  are  doomed 
to  die  from  the  beginning.  The  worst  of  these  die  soon  after  they  are 
shot.  The  wounds  received  in  the  explosive  zone  belong  to  this  class. 
Col.  J.  Van  R.  Hoff,  Medical  Corps,  U.  S.  Army,^  reports  that  at  short 
range  the  reduced-caliber  bullet  of  the  Japanese  when  striking  the  full 
stomach   caused  great  laceration  and  bursting   of  the   organ  from 

1  War  Dept.  Report  Gen'l.  Staff,  No.  3,  Oct.  1,  1906. 
17 


248  GUNSHOT   WOUNDS 

surrounding  attachments.  Like  results  were  observed  with  a  full 
bladder,  and  the  solid  organs.  In  these  cases  death  ensues  very  early 
from  shock  and  hemorrhage.  Hoff  testifies  to  the  fatality  attending 
abdominal  wounds  from  ricochet  rifle  bullets,  also  from  shrapnel 
balls,  and  shell  fragments. 

Captain  Eugenio  de  Sarlo^  from  the  recent  Italo-Turkish  war  in 
North  Africa  states  that  laparotomy  in  the  field  should  be  limited  to 
the  utmost — to  cases  in  which  fatal  hemorrhage  is  taking  place.  Aside 
from  the  fact  that  laparotomies  were  generally  attended  with  fatal 
results,  too  many  wounded  required  the  precious  time  that  must  be 
devoted  to  the  comparatively  few  who  were  hit  in  the  abdomen.  In- 
stead of  laparotomy  the  Italian  surgeons  employed  hypodermoclyses, 
subcutaneous  injections  of  morphine,  ice  bags  to  the  abdomen  and  the 
interdiction  of  food  for  several  days.  This  treatment  gave  55  per  cent, 
of  cures  according  to  the  reporter  and  the  happy  outcome  is  attrib- 
uted to  the  adhesive  property  of  the  peritoneum  which  tends  to 
circumscribe  the  part  injured,  and  to  the  defensive  action  of  the 
omentum,  and  closing  of  the  small  orifice  as  a  result  of  hernia  of  the 
mucosa. 

We  believe  we  have  written  enough  upon  gunshot  wounds  in  battle 
to  show  that  there  are  many  among  the  wounded  who  recover,  and 
more  who  die.  The  former  seem  surprisingly  large  because  of  the  large 
number  of  wounds  which  come  under  the  notice  of  the  surgeons  at 
one  time,  and  the  statistics  of  recoveries  seem  to  be  especially  good 
because  they  are  gathered  from  the  less  serious  cases  and  as  already 
stated  because  many  of  the  favorable  cases  result  from  the  use  of  small- 
bore rifle  bullets  at  ranges  beyond  the  zone  of  explosive  effects. 

From  the  foregoing  it  appears  that  the  rule  in  civil  practice  has  been 
to  operate  on  all  cases  of  penetrating  and  perforating  gunshot  wound 
of  the  abdomen,  and  in  military  practice  in  active  campaign  the  rule 
is  to  operate  only  on  cases  exhibiting  symptoms  of  internal  hemor- 
rhage. So  far  as  the  practice  in  active  campaign  is  concerned  the  rule 
will  have  to  stand  until  we  can  change  the  unfavorable  environments, 
a  thing  hardly  possible. 

As  to  the  rule  to  be  followed  in  civil  practice  this,  as  we  have 
already  shown,  was  based  upon  statistics  of  operated  and  non-operated 
cases,  and  the  latter  made  such  a  poor  showing  that  laparotomy  under 

^  Notes  on  Wounded  at  Derna  by  Captain  de  Sarlo.  Caducee,  Nov.  16,  1912. 
Ed.  Saval. 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN  249 

favorable  conditions  was  established  with  apparent  reason.  In  the 
earlier  history  of  the  operative  treatment  the  showing  was  far  more 
favorable  to  operation  than  it  has  become  in  recent  years.  As  we 
have  already  stated  the  results  of  the  laissez-faire  treatment  of  the 
military  sm-geon  have  awakened  the  attention  of  sm-geons  in  civil  prac- 
tice. They  are  now  revising  their  later  statistics  and  a  study  of  these 
make  it  a  question  if  operation  in  all  cases  is  the  proper  rule  to  follow. 
In  approaching  this  subject  of  the  treatment  to  be  adhered  to  in  civil 
hospitals  we  have  to  remind  our  civil  confreres  that  military  statistics 
for  their  purpose  are  very  much  one-sided.  We  only  take  cognizance 
of  the  cases  which  reach  hospital  care  and  they  are  those  for  the  most 
part  that  have  survived  a  number  of  hours  already — they  are  the  cases 
which  have  survived  shock  more  or  less  and  that  have  not  died  of 
internal  hemorrhage.  If  our  statistics  were  made  up  from  all  the 
cases  as  thej^  are  in  civil  life,  and  if  these  cases  were  all  operated  upon 
as  they  generally  are  in  civil  hospitals,  the  percentage  of  mortality 
of  our  operated  cases  would  be  enormous,  because  the  character  of  the 
wounds  in  those  that  die  soon  after  they  are  hit  by  rifle  bullets — in  the 
explosive  zone — and  from  pieces  of  shells  and  shrapnel  balls,  are  doomed 
to  die  under  any  method  of  treatment. 

We  have  collected  the  results  in  144  cases  of  penetrating  gunshot 
wounds  of  the  abdomen  from  the  Annual  Reports  of  the  Surgeon 
General,  U.  S.  A.,  from  1898  to  1910  inclusive.  Of  this  number  fifty- 
eight  cases  were,  treated  by  laparotomy  with  a  mortality  of  67  per 
cent. ;  and  eighty-six  cases  were  treated  expectantly  with  a  mortality 
of  seventy  per  cent.  Doubtless  many  of  the  cases  treated  expectantly 
were  so  treated  on  account  of  the  gravity  of  the  injuries  or  because  of 
the  unfavorable  surroundings  for  operation. 

Twenty-nine  of  the  laparotomies  were  reported  for  the  years  1898 
to  1902  which  corresponds  to  the  years  of  active  field  operations 
during  the  Spanish-American  War  and  Philippine  Insurrection.  The 
cases  were  operated  upon  no  doubt  mostly  under  the  unfavorable 
conditions  that  obtain  in  war.  The  mortality  for  this  group  is  71 
per  cent.  The  remaining  twenty-nine  laparotomies  were  done  between 
the  years  1903  and  1910,  which  corresponds  to  garrison  conditions  in 
which  the  surgeons  have  access  to  fixed  hospital  accommodations  and 
for  this  group  the  mortality  is  62  per  cent.  Compared  to  results  which 
we  will  show  later  these  results  are  in  keeping  with  those  in  other  armies 
for  field  conditions,  and  the  garrison  cases  compare  favorably  with 
those  in  some  of  our  large  civil  hospitals. 


250  GUNSHOT   WOUNDS 

The  missiles  inflicting  the  wounds  in  the  144  cases  are  not  suffi- 
ciently well  designated  to  give  any  idea  of  their  caliber  or  composition. 
One  hundred  and  twenty  of  the  wounds  were  inflicted  by  bullets,  two  by 
shells,  three  by  shrapnel,  one  by  lantaca  slug,  and  eighteen  not  stated. 
'We  may  take  for  granted  that  the  majority  of  the  wounds  caused  by 
bullets  resulted  from  steel-packed  reduced-caliber  bullets.  Quite  a 
number  were  inflicted  by  .38-caliber  brass-jacketed  Remington  rifle 
bullets.  Beyond  that,  the  nature  of  the  projectiles  cannot  be  defi- 
nitely stated,  which  gives  an  indefinite  idea  of  the  nature  of  the 
wounds.  In  reporting  gunshot  injuries  practitioners  should  be  more 
specific  in  describing  the  nature  of  the  projectiles.  This  is  a  fault 
common  to  both  military  and  civil  practitioners.  Surgeons  generally 
should  be  impressed  with  the  fact  that  there  are  gunshot  wounds  and 
gunshot  wounds.  That  the  character  of  the  lesion  in  a  given  case  and 
the  prognosis  thereof  is  largely  influenced  by  the  velocity  and  the  sec- 
tional area  normally  present  in  the  projectile  and  what  may  be  ac- 
quired by  deformation. 

Later  statistics  from  civil  hospitals  and  individual  practitioners 
tend  to  show  that  a  series  of  non-operated  cases  nowadays  does  better 
without  operation.  Dr.  Rudolph  Matas  of  New  Orleans  was  kind 
enough  to  look  over  the  statistics  of  Charity  Hospital  in  that  city, 
where  so  many  cases  of  gunshot  wounds  are  treated  annually.  He 
informs  us  that  according  to  Doctor  T.  G.  Richardson  in  the  five  years 
preceding  May,  1887,  in  the  time  when  operative  treatment  was  not 
employed,  the  mortality  for  non-operative  cases  of  penetrating  gun- 
shot wound  of  the  abdomen  was  59.4  per  cent.  This  can  be  taken  as  a 
basis  for  the  chance  of  recovery  by  the  expectant  plan  of  treatment 
from  gunshot  of  this  region  by  projectiles  from  pistols  and  revolvers 
of  low  velocity  and  moderate  calibers  so  much  used  in  civil  life  at 
about  this  time. 

The  first  group  of  cases  operated  upon  at  this  hospital  was  by  Doc- 
tor A.  B.  Miles,  who  reported  thirteen  cases  in  1893,  with  a  mortality 
of  60  per  cent.  The  percentage  of  recoveries  was  40  per  cent.,  which  is 
practically  the  same  as  in  those  not  operated  and  reported  by  Richard- 
son, viz.,  40.6  per  cent. 

Later,  in  1896,  Doctor  W.  E.  Parker,  assistant  surgeon  of  the  hospi- 
tal, operated  thirteen  times  with  53.8  per  cent,  mortality,  46.2  per  cent, 
recoveries. 

Later,  Matas  and  Hynes  (not  published)  compiled  all  cases  for  the 
decade  1890-1900  treated  by  the  Surgeons  of  Charity  Hospital: 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN 


251 


Cases 

Deaths 

Mortality    ■■ 

Operated 

Non-operated 

Total 

122 
112 
234 

84 

60 

144 

68.85  per  cent. 
53.57  per  cent. 
61  .-5     per  cent. 

which  makes  the  expectant  and  conservative  mode  of  treatment  more 
favorable  by  15  per  cent. 

For  the  same  hospital  Dr.  E.  D.  Fenner  (Annals  of  Surgery,  Vol. 
XXXV,  1902,  page  15)  compiled  113  cases  of  penetrating  gunshots 
of  the  abdomen  treated  by  laparotomy  with  a  mortality  of  69  per  cent. 
The  mortality  was  still  larger,  73.95  per  cent,  in  cases  that  were  compli- 
cated by  visceral  injury. 

In  1905  Dr.  H.  R.  Shands,  resident  interne  of  the  hospital,  wrote  a 
thesis  which  deals  with  some  of  the  statistics  of  the  hospital  as  follows : 
150  penetrating  wounds  of  the  abdomen  were  treated  in  the  hospital 
for  the  four  years  Jan.,  1901,  to  Jan.,  1905. 


Gunshot  wounds 


Abdomen     Deaths 


Mortahty 


Perforating 118  81  68.7  per  cent. 

Operated 59  46  77.9  per  cent. 

Non-operated 59  34  57 , 6  per  cent. 

I  i 

(73.7  per  cent,  of  these  gunshot  wounds  occurred  in  negroes.) 

The  injury  sustained  by  the  various  organs  was  ascertained  in  fifty- 
four  of  the  fifty-nine  cases  as  follows:  Intestines  were  wounded  in 
79.6  per  cent.  The  stomach  in  22.2  per  cent.  The  bladder  13  per 
cent.  The  kidney  in  3.7  per  cent.  The  spleen  in  1.8  per  cent.  The 
liver  in  5.5  per  cent.  Perforations  of  the  intestines  ranged  from  one  to 
nineteen  in  number,  and  those  of  the  stomach  ranged  from  one  to 
four  in  number. 

In  339  cases  of  penetrating  gunshot  wounds  of  the  abdomen  com- 
piled by  Doctor  C.  W.  Allen  for  the  years  1899  to  1908  inclusive,^  there 
were  221  deaths  or  a  mortality  of  64.7  per  cent.     In  this  series,  the 


1  N.  O.  Med.  and  Surg.  Jour.,  Sept.,  1911. 


252 


GUNSHOT   WOUNDS 


operated  and  non-operated  cases  are  included  together,  and  the  mor- 
tality given  is  regardless  of  the  plan  of  treatment  followed. 

The  last  series  noted  is  185  cases  for  the  years  1908  to  1911  inclu- 
sive with  a  mortality  of  113  or  an  average  mortality  of  60  per  cent. 
As  in  the  preceding  series  no  attempt  was  made  to  separate  the  oper- 
ated from  the  non-operated  cases. 

Doctor  Matas  who  has  been  connected  with  this  great  hospital 
for  manj"  years  states  that  "since  1905  the  operative  treatment  seems 
to  grow  less  and  less  in  favor  in  the  estimation  of  the  house  officers, 
and  the  mortality  as  exhibited  in  the  last  five  annual  reports  is  practic- 
ally the  mortality  of  the  expectant  or  non-operative  treatment.  This 
average  mortality  of  60  per  cent,  for  the  five  years  mentioned  is  almost 
the  same  as  the  mortality  which  Richardson  found  for  the  five  years 
preceding  1887,  viz.,  59.4  per  cent.,  and  which  was  adopted  as  an  aver- 
age mortalit}^  for  non-operated  cases.  This  is  certainly  far  better 
than  the  average  mortality  for  the  group  of  operated  cases  as  shown 
in  the  following  recapitulation: 


Operated 

cases 

Deaths 

Mortality 

Matas  and  Hynes,  1890- 

1900. 
Dr.  H.  E.  Shands,  1901- 

1905. 

122 
59 

84 
46 

68 .  85  per  cent. 
77 . 9    per  cent. 

Total 

181 

130 

average      71.8    percent. 

These  results,  for  the  operative  treatment,  certainl}^  form  a  wide  de- 
parture from  those  attained  by  Dr.  W.  E.  Parker,  who  was  himself  a 
resident  interne  in  Charity  Hospital,  and  who,  as  already  stated  on 
page  243,  showed  that  in  the  operated  cases  within  the  first  seven  hours 
of  perforating  gunshot  wounds  of  the  hollow  viscera,  the  mortality 
was  brought  as  low  as  47  per  cent.  Parker's  results  are  better  than 
Seigle's  series,  which  gave  a  fatality  of  51.6  per  cent.;  not  so  good  as 
the  latter's  cases  operated  upon  within  four  hours,  which  was  15.2 per 
cent.,  nor  Richard  Douglas'  results  which  gave  a  mortality  of  32.3  per 
cent,  for  all  cases. 

The  figures  above  quoted  for  Charity  Hospital  lead  one  to  believe 
that  the  results  in  gunshot  wounds  under  the  operative  mode  of  treat- 


GUNSHOT   WOUNDS    OF   THE    ABDOMEN  253 

ment  are  worse  than  formerlj^     Taking  this  for  granted,  what  reason 
can  we  give  to  explain  the  change. 

1.  Is  it  due,  as  some  have  suggested,  to  the  fact  that  the  lapa- 
rotomies which  were  once  undertaken  by  surgeons  of  mature  judge- 
ment and  prolonged  experience  in  abdominal  work  are  now  performed 
by  the  house  staff,  young  men,  who  have  no  personal  experience,  and  less 
dexterity,  to  do  an  operation  with  the  necessary  perfection  and  rapidity 
that  this,  the  greatest  of  all  emergency  operations  known  to  surgery, 
requires?  or 

2.  Is  it  due  to  a  change  in  the  lesion  of  gunshot  wounds  to-day  as 
compared  to  the  lesion  of  twenty  or  more  years  ago. 

The  first  of  these  questions  can  be  answered  by  the  visiting  staff 
of  the  hospitals  concerned,  and  in  order  to  find  an  answer  to  the  second 
question,  we  know  that  the  change  in  the  character  of  gunshot  wounds 
in  civil  practice  has  been  coincident  ^vith  the  evolution  in  firearms,  the 
same  as  in  military  practice. 

During  the  earlier  use  of  firearms  in  civil  life  the  projectiles  from 
pistols  and  rifles  were  round,  of  large  calibers  and  low  velocities.  Later 
conoidal  bullets  were  used,  when  there  was  marked  reduction  in  the  cali- 
ber and  weight  of  projectiles  with  some  addition  to  the  velocity.  The 
crashing  effects  of  conoidal  bullets  over  those  of  the  low-velocity  spheri- 
cal balls  is  well  remembered  by  surgeons  still  living.  At  this  stage  in 
the  evolution  of  firearms  there  came  a  tendency  to  retain  the  smaller 
calibers  with  no  marked  tendency  to  increase  the  velocity  of  projectiles. 
This  was  a  time  in  the  evolution  of  firearms  that  just  preceded  the  use 
of  the  high  explosives.  Bullets  from  pistols  and  revolvers  of  that  day 
— about  two  decades  and  more  ago — caused  wounds  the  size  of  their 
sectional  areas  with  an  amount  of  destruction  proportional  to  the  range. 
The  velocity  was  low  compared  to  that  impressed  on  the  bullets  of  to- 
day, and  there  was  a  great  tendency  for  projectiles  to  lodge.  There 
were  then  many  patterns  of  pistols  and  revolvers  in  the  market,  of 
small  calibers,  ranging  from  .22,  .32,  to  .38  calibers,  from  which  wounds 
were  inflicted  in  personal  combat.  These  weapons  were  very  much 
used  about  the  time  surgeons  first  commenced  to  perform  laparotomy 
as  a  measure  of  treatment  in  gunshot  wounds  of  the  abdomen.  The 
lesions  which  they  inflicted  were  not  attended  with  much  laceration  and 
contusion.  The  favorable  results  in  the  operated  cases  were  marked, 
and  they  attracted  the  attention  of  surgeons  generally.  It  then  be- 
came the  fashion  to  open  the  abdomen  in  all  cases  wherever  surgeons 
could  master  the  environments,  for  exploratory  purposes  at  least.     This 


254  GUNSHOT   WOUNDS 

was  the  status  of  the  subject  at  the  time  that  the  high-power  explosives 
came  into  use.  In  Chapter  No.  1,  on  Firearms,  Explosives,  Pro- 
jectiles and  the  Ballistics  of  the  latter,  as  well  as  in  the  Characteristic 
Features  of  Gun-shot  Wounds  as  detailed  in  Chapter  II,  we  have  sought 
to  show  the  changes  in  wounds  from  one  period  to  the  next. 

The  introduction  of  nitrocellulose  compounds  has  conferred  marked 
velocity  on  lead  projectiles  of  the  pistol  class,  and  now  that  the  pro- 
jectiles for  these  weapons  are  enveloped  in  a  jacket  of  hard  steel,  as  in 
the  so-called  automatic  pistols,  the  velocities  have  become  doubled  and 
trebled  for  this  class  of  hand  weapons,  with  no  tendency  in  the  reduc- 
tion of  caliber. 

As  we  have  aleady  stated  in  Chapter  II,  under  Wounds  caused  by 
Pistols  and  Revolvers,  the  effects  of  this  additional  velocity  on  the 
short,  already  unstable  bullet,  has  been  to  render  it  more  so.  The 
projectile  loses  its  balance  when  encountering  the  least  resistance.  It 
then  travels  at  a  tangent  to  its  line  of  flight,  or  turns  end  over  end, 
and,  making  an  irregular  impact,  it  lacerates  and  mutilates  tissues,  in- 
flicting conditions  most  favorable  to  the  development  of  existing  in- 
fection. In  such  a  case  laparotomy  cannot  remedy  the  damage  done 
in  the  way  of  hematomata  and  contusion  about  the  bullet's  channel, 
and  the  patient  is  doomed  to  a  fatal  issue  from  the  beginning.  The 
instability  of  the  bullet  as  just  mentioned  may  be  likened  to  the  in- 
stability that  has  recently  been  conferred  on  the  latest  projectile  of  the 
reduced  caliber  rifle — the  bullet  S  of  some  authors,  the  one  recently 
adopted  by  this  country,  England  and  Germany  and  described  on  page 
56.  We  in  the  military  service  will  witness  the  same  changes  in  gun- 
shot wounds  of  the  abdomen  that  the  surgeons  in  civil  life  are  witnessing 
from  automatic  pistols  and  revolvers  now.  We  predict  that  no  ob- 
server will  ever  again  say,  as  Follenfant  has  said,  of  the  wounds  by 
the  25.5  Japanese  rifle,  ''that  the  beneficence  from  the  use  of  reduced 
calibers  in  war  has  even  extended  to  gunshot  injuries  of  the  abdomen." 

In  the  recent  Turko-Balkan  war  Major  P.  C.  Fauntleroy,^  M.  C, 
U.  S.  A.,  reports  that  among  the  Bulgarian  soldiers  the  large  majority 
of  the  abdominal  wounds  died  on  the  field  or  in  a  few  days  from 
septic  peritonitis.  The  very  few  that  reached  the  base  hospitals  re- 
quired laparotomy  for  intra-peritoneal  abscess.  The  Turkish  army 
was  armed  with  the  German  Mauser  of  reduced  caliber,  firing  the  spitz 
bullet  which  corresponds  to  our  pointed  bullet.  Notwithstanding  the 
fact  that  the  Turko-Balkan  war  referred  to  was  fought  with  more  field 
1  Op.  cit. 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  255 

artillery,  and  the  proportion  of  wounds  by  shrapnel  is  larger  than 
noted  in  any  previous  war,  we  have  reason  to  believe  that  the  spitz 
bullet  has  helped  materially  to  swell  the  mortality  among  those  hit  in 
the  abdomen.  Between  the  deadly  body  wounds  of  the  shrapnel  ball 
and  the  mutilating  effects  of  the  pointed  bullet  of  the  military  rifle,  the 
future  of  laparotomy  in  field  surgery  is  less  promising  than  ever. 

Finally  we  may  add  that  abdomenal  wounds  in  both  Civil  and 
Military  practise  will  hereafter  be  inflicted  by  very  unstable  bullets, 
which  travelling  at  great  volocity,  will  produce  ugly  lesions  that  will 
seldom  prove  amenable  to  operative  treatment. 

In  the  presence  of  a  penetrating  gunshot  wound  of  the  abdomen 
the  military  surgeon  in  campaign  or  civil  surgeon  in  peace  must  decide 
at  once  upon  the  advisability  of  operation. 

Contraindications  to  Operation. — (1)  A  moribund  condition,  or 
increasing  shock  bordering  upon  profound  collapse  with  impending 
death,  contraindicates  surgical  aid. 

(2)  If  twelve  hours  have  elapsed  since  the  receipt  of  the  injury  the 
chances  of  recovery  are  bad.  The  surgeons  in  each  case  should,  how- 
ever, be  the  judges  of  the  advisability  for  operation,  using  the  condition 
of  the  patient  as  a  guide. 

(3)  When  symptoms  of  peritonitis  are  evident,  there  is  but  little 
hope  of  recovery  from  operation. 

(4)  Unfavorable  environments,  inexperience  on  the  part  of  the 
attending  surgeon  and  his  assistants,  materially  reduce  the  chance  for 
recovery  after  operation. 

(5)  Avoid  operation  on  cases  complicated  by  severe  wounds  of  the 
chest  such  as  would  contraindicate  the  use  of  an  anesthetic. 

(6)  It  is  a  question  if  operation  is  advisable  in  cases  where  the 
point  of  entrance  is  some  distance  from  the  mid  line  of  the  abdomen, 
with  the  course  of  the  ball  ranging  antero-posteriorly.  Still  if  opera- 
tion is  done  under  favorable  environments  no  harm  can  result.  In 
these  cases  the  large  intestine  has  generally  suffered  perforation.  The 
perforation  lies  in  contact  with  the  parietal  peritoneum,  the  intestine 
is  immobile,  and  in  the  case  of  perforation  from  small  calibers,  the 
intestinal  contents  being  solid,  extravasation  is  infrequent. 

(7)  When  the  patient  is  doing  well,  as  often  happens  in  military 
practice  after  gunshot  by  reduced  calibers  eighteen  to  twenty-four 
hours  after  the  receipt  of  the  injury,  operation  should  be  withheld. 
Peritonitis  more  or  less  localized  is  present  in  all  these  cases,  and  hand- 
ling of  the  inflamed  peritoneal  surfaces  in  search  of  perforations  will 


256  GUNSHOT   WOUNDS 

do  more  harm  than  no  operation.  Indications  for  operation  in  local- 
ized peritonitis  may  show  itself  later,  and  when  it  does  the  danger 
from  operation  is  trifling.  Again  cases  that  have  survived  eighteen 
to  twenty-four  hours  in  military  practice  especially  belong  usually 
to  that  class  in  which  extravasation  has  failed  to  take  place  as  a  result 
of  the  small  wound  caused  by  the  rifle  bullet.  This  small  opening  is 
usually  closed  by  hernia  of  the  mucosa  and  exudation  of  plastic 
lymph,  before  extravasation  has  had  time  to  take  place;  and  finally, 
some  of  the  cases  in  military  practice  which  have  shown  negative  or 
trifling  symptoms  after  the  lapse  of  the  time  above  referred  to,  no 
doubt  belong  to  the  rare  class  of  cases  that  sustain  no  perforation, 
although  the  small  bullet,  as  already  pointed  out,  may  have  crossed 
the  intestinal  area. 

(8)  Laparotomy  in  mililary  practice  during  active  field  conditions 
has  proven  a  failure  for  a  number  of  reasons.  Military  surgeons  in 
campaign  seldom  get  the  opportunity  to  operate  early.  The  cases  are 
first  seen  at  the  advanced  stations  where  the  facilities  for  abdominal 
work  seldom  exist.  The  lack  of  water  and  sterile  dressings,  the  diffi- 
culties which  arise  from  proper  shelter,  and  an  equable  temperature 
under  canvas  in  all  seasons  of  the  year,  as  well  as  the  difficulties  that 
arise  from  wind,  dust,  flies,  etc.,  all  combine  to  preclude  aseptic  work, 
under  fleld  conditions.  When  the  wounded  finally  reach  the  field 
hospitals  where  facilities  for  abdominal  work  are  to  be  found,  the  time 
for  safety  in  operation  has  gone  by,  and  if  it  has  not,  the  surgeons  are 
so  occupied  in  doing  necessary  work  on  a  great  number  of  other 
wounded  that  common  justice  to  the  greater  number  does  not  permit 
the  employment  of  a  large  operating  staff,  with  the  necessary  time  and 
personnel,  to  be  detached  to  do  abdominal  work  on  a  comparatively 
few  wounded. 

Indications  for  Operation. — (1)  Protrusion  of  the  intestine  from  the 
wound  soiled  by  dirt  and  feces,  when  the  patient's  condition  permits, 
demands  immediate  operation,  even  though  the  surroundings  are  not 
entirely  satisfactory. 

(2)  When  the  symptoms  indicate  that  internal  hemorrhage  is 
going  on,  the  chance  of  saving  life  by  laparotomy  and  the  ligation  of 
bleeding  vessels  should  be  undertaken  though  the  environments  are 
precarious. 

(3)  When  a  bullet  has  crossed  the  intestinal  area,  if  the  time  after 
the  injury  and  the  environments  permit,  laparotomy  should  be  done 
promptly. 


GUNSHOT   WOUNDS    OF    THE    ABDOMEN  257 

Operation:  Having  determined  by  the  condition  of  the  patient 
and  the  nature  of  the  injury  that  abdominal  section  is  necessary  the 
patient  should  be  anesthetized  with  ether  preferably.  A  median 
incision  giving  ample  room  should  be  made  in  all  cases  in  which 
the  ball  has  entered  near  the  mid  line  and  in  which  the  track  of  the 
bullet  has  crossed  a  median  plane.  When  the  course  of  the  ball  is 
well  established  and  located  laterally  the  incision  may  be  made  over 
the  corresponding  side.  Upon  reaching  the  abdominal  cavity  bleed- 
ing should  be  promptly  arrested  by  ligation,  or  pressure  with  a  gauze 
pad.  The  extravasated  blood  should  next  be  removed  from  the 
peritoneal  cavity  by  sponging. 

Intestinal  perforation  should  be  closed  by  suture  at  once  if  small, 
and  when  large  the  lumen  above  and  below  the  perforation  should 
be  clamped  "with  rubber-covered  forceps  for  the  time  being.  The 
method  of  repair  of  the  latter  and  all  visceral  injuries  will  be  dealt 
with  under  appropriate  headings  later. 

Drainage  should  be  employed  wherever  the  lacerated  condition 
of  the  tissues  tends  to  cause  necrosis,  and  whenever  bleeding  surfaces 
require  the  application  of  pressure  by  tamponade.  The  latter  is 
preferable  to  the  actual  cautery,  which  should  be  avoided. 

Stimulation  by  strychnia  sulphate  hypodermically,  and  the  use  of 
salt  solution  with  adrenalin,  should  be  employed  whenever  the  patient's 
condition  demands  it. 

Wounds  of  the  Small  Intestine. — In  point  of  frequency  wounds  of 
the  small  intestines  take  precedence  over  the  rest  of  the  abdominal 
viscera.  As  we  have  already  intimated  the  small  intestines  make  a 
marvelous  escape  in  a  certain  percentage  of  antero-posterior  shots, 
but  it  may  be  laid  down  as  a  rule  that  transverse  and  oblique  shots, 
through  the  abdomen  in  the  vast  majority  of  cases  cause  multiple 
perforations  of  the  intestinal  tube.  As  many  as  twenty-eight  perfora- 
tions have  been  thus  encountered.  Free  extravasation  of  fluid  fecal 
matter  is  favored  by  the  number  of  perforations.  Some  of  the  latter 
are  slit-like  tears,  which  occur  in  the  long  axis  of  the  gut.  The  ten- 
dency to  the  early  development  of  septic  peritonitis  is  almost  invaria- 
ble. In  penetrating  wounds  of  the  abdominal  cavity  the  small  intes- 
tines are  said  to  be  perforated  in  65  per  cent,  of  the  cases  and  death 
will  take  place  in  percentages  which  will  vary  with  the  character  of 
the  lesion,  and  the  latter,  as  we  have  already  stated,  depends  largely 
upon  the  sectional  area  and  velocity  of  the  projectile.  Peritonitis 
and  internal  hemorrhage  are  the  common  causes  of  death.     Perfora- 


258  GUNSHOT   WOUNDS 

tions  from  small  calibers  are  usually  closed  by  hernia  of  the  mucosa. 
The  escape  of  the  contents  is  further  aided  in  some  cases  by  arrest 
of  peristalsis  and  the  presence  of  plastic  lymph,  which  is  thrown  out 
in  a  short  space  of  time.  The  hernia  caused  by  the  everted  mucosa 
may  occlude  the  perforation  so  perfectly  that  hemorrhage  will  find 
no  access  to  the  lumen  of  the  gut,  so  that  in  cases  of  multiple  perfora- 
tion there  may  be  httle  or  no  blood  in  the  stools.  Wounds  of  the 
mesenteric  border  favor  the  presence  of  hemorrhage.  Injury  to  the 
blood  supply  of  certain  areas  of  gut,  as  occurs,  for  instance,  in  shots 
through  the  mesenteric  border  without  perforation  of  the  gut,  is  apt 
to  end  in  gangrene.  Perforative  septic  peritonitis  usually  develops, 
in  the  first  few  hours.  Depending  upon  the  virulency  of  the  infection, 
death  will  occur  in  thirty-six  to  forty-eight  hours  in  the  large  majority 
of  cases. 

The  tendency  to  hemorrhage,  or  the  development  of  peritonitis, 
depends  largely  upon  the  character  of  the  wound.  Wounds  by  small 
calibers,  animated  by  low  velocity,  are  prone  to  local  peritonitis  or 
recovery.  No  doubt  many  of  the  soldiers  who  recover  so  unexpectedly 
in  mihtary  practice  owe  their  lives  to  the  small  perforations  that 
result  from  projectiles  of  reduced-caliber  rifles  with  low  remaining 
velocities.  Surgeons  in  civil  life  get  their  best  results  in  operated  and 
non-operated  cases  from  wounds  inflicted  by  the  smaller  calibers. 

Symptoms. — While  dealing  with  general  symptoms  of  gunshot 
wounds  of  the  abdomen,  to  which  the  reader  is  referred,  we  mentioned 
all  the  symptoms  hkely  to  arise  from  injury  to  the  small  intestine. 
The  surgeon  should  be  on  the  alert  for  the  presence  of  hemorrhage, 
as  this  is  the  condition  next  to  shock  that  will  require  his  immediate 
attention.  Unhke  shock,  it  does  not  yield  to  remedial  measures,  and 
it  is  not  so  readily  diagnosed.  Hemorrhage  will  not  appear  externally 
unless  it  be  in  the  case  of  large  external  wounds.  We  must  look  for 
the  presence  of  fluid  in  the  abdominal  cavity  as  this  is  revealed  to  us 
by  physical  signs.  Areas  of  dullness  which  progressively  increase 
about  the  flanks,  associated  with  persistent  shock,  indicate  that  hemor- 
rhage is  going  on. 

Treatment. — The  treatment  of  gunshot  wounds  of  the  small  intes- 
tines requires  that  all  perforations  be  located  by  searching  the  entire 
length  of  the  gut.  To  do  this  properly  without  overlooking  some  of 
the  perforations,  it  is  better  to  commence  the  search  at  the  iliocecal 
junction,  tracing  the  small  intestine  rapidly  upward,  each  loop  being 
carefully  returned  as  soon  as  examined.     Perforations  should  be  closed 


GUNSHOT   WOUNDS    OF   THE    ABDOMEN  259 

as  found.  Large  perforations  and  injuries  on  the  mesenteric  border 
that  call  for  resection  should  be  controlled  by  clamps  and  passed  over 
to  be  attended  to  later.  Small  perforations  on  the  convex  border  of 
the  small  intestine  may  be  closed  by  continued  or  purse-string  suture. 
Larger  perforations  are  closed  by  a  line  of  seromuscular  sutures  running 
with  the  short  axis  of  the  gut,  and  when  necessary  two  lines  of  sutures, 
one  to  include  all  the  coats,  and  a  superficial  line  to  include  the  sero- 
muscular layer.  In  much  larger  perforations  the  line  of  sutures  should 
run  in  a  direction  coincident  with  the  lumen  of  the  gut  provided  not 
more  than  one-half  the  lumen  is  taken  up  by  the  suturing,  otherwise 
resection  is  called  for. 

Special  care  is  required  in  dealing  with  injuries  at  the  mesenteric 
border  lest  gangrene  of  the  gut  takes  place  from  interference  with  the 
blood  supply.  Injuries  involving  1/2  inch  or  more  of  the  tissue  in 
this  location  demand  resection;  any  injury  less  than  1/2  inch  may 
be  closed  by  suture  depending  upon  the  judgment  of  the  operator. 

Wounds  between  the  mesenteric  and  convex  borders  when  located 
nearer  the  former  may  at  times  threaten  the  blood  supply  of  the  con- 
vex border.  In  such  cases  resection  is  called  for.  All  suturing  should 
be  done  with  a  straight  needle  threaded  with  fine  silk,  six  interrupted 
sutures  to  the  inch  will  suffice.  When  resection  is  done  the  end-to-end 
approximation  should  be  accomplished  with  the  Czerny-Lembert 
suture  and  in  cases  where  the  operator  is  not  experienced  or  where  it 
is  necessary  to  save  time  a  Murphy  button  should  be  used.  When 
two  or  more  resections  are  to  be  performed  in  the  course  of  2  or  3  feet 
of  gut,  it  is  better  to  sacrifice  all  of  the  intervening  gut  and  bring  the 
ends  together  by  one  circular  enterorrhaphy,  rather  than  prolong  the 
operation  and  add  to  the  shock  by  doing  two  resections. 

Search  for  perforations  in  the  large  intestine  is  made  by  using  the 
ilio-cecal  valve  as  a  starting  point  and  tracing  the  gut  upward.  Closure 
of  perforations  to  large  intestines  covered  b}^  peritoneum  is  similar  to 
those  in  the  small  intestine,  the  line  of  suture  with  reference  to  the  axis 
of  the  gut  is  not  so  important,  and  resections  are  seldom  called  for. 

After  all  perforations  have  been  repaired  cleansing  the  peritoneal 
cavity  is  next  in  order.  Irrigation  is  not  advisable  unless  deemed 
necessary  from  extensive  fouling  by  the  contents  of  the  afimentary 
canal.  Localized  extravasations  are  best  removed  with  moist  sponges. 
If  irrigation  is  necessary,  it  should  be  done  by  flushing  the  peritoneal 
cavity  with  hot  normal  salt  solution. 

In  all  cases  it  is  safer  to  drain  than  not  to  drain.     Drainage  at  the 


260  GUNSHOT   WOUNDS 

most  dependent  point  is  specially  indicated  in  cases  likely  to  be  followed 
by  coagulation  necrosis  and  those  where  extravasation  has  been  marked. 

Gunshot  Wounds  of  the  Stomach. — Wounds  of  the  stomach  were 
very  fatal  in  the  days  of  the  old  armament.  Aside  from  the  dangers  of 
sepsis,  the  wounds  of  that  day  were  large  and  there  was  always  danger 
of  free  extravasation  of  the  irritating  stomach  contents  with  resulting 
peritonitis,  and,  as  the  records  show,  great  tendency  to  subphrenic 
abscess. 

In  the  distended  state,  the  relation  of  the  stomach  wall  to  the  par- 
ietes  makes  it  an  easy  target  for  perforation.  In  point  of  frequency 
wounds  of  the  stomach  come  after  those  of  the  intestine  and  liver. 
There  were  sixty-four  cases  treated  in  our  hospitals  during  the  Civil 
War,  but  on  account  of  the  fatal  character  of  complicating  wounds  to 
adjacent  organs,  this  number  only  represented  a  fraction  of  the  wounds 
of  the  stomach  received  in  action. 

In  recent  wars  uncomplicated  wounds  of  the  stomach  have  frequently 
ended  in  recovery.  This  has  been  attributed  to  the  empty  condition 
of  the  organ  which  so  often  obtains  among  soldiers  in  active  campaign, 
the  thickness  of  the  stomach  wall,  and  the  narrow  channel  made  by 
the  bullet.  Stevenson  mentions  twelve  cases  in  the  Anglo-Boer  War 
with  two  deaths,  one  as  a  result  of  peritonitis  and  the  other  from 
hemorrhage.  FoUenfant  states  that  the  statistics  at  Kharbine  in  1904 
gave  forty-two  deaths  out  of  252  penetrating  wounds  of  the  abdomen, 
with  lesion  of  the  stomach  and  intestine. 

Wounds  of  the  stomach  are  apt  to  be  complicated  by  the  presence 
of  other  wounds  such  as  those  of  the  left  kidney,  spleen  ,Hver,  pancreas, 
transverse  colon,  diaphragm  and  thoracic  viscera. 

The   prognosis    as    reported    by    different    authors    is    variable. 
Laplace^  has  found  gunshot  wounds  from  small  calibers  to  end  in^ 
recovery  in  the  majority  of  his  cases,  while  MacCormac^  states  that 
99  per  cent,  of  gastric  perforations  end  in  death. 

The  prognosis  of  uncomplicated  stomach  wounds  will  largely  depend 
upon  the  character  of  the  wound  as  influenced  by  sectional  area,  veloc- 
ity, and  resistance  on  impact.  Wounds  inflicted  by  the  high-power  rifle 
at  proximal  ranges  will  show  explosive  effects  in  accordance  with  the 
amount  of  fluid  in  the  viscus.  All  wounds  showing  explosive  effects  are 
rapidly  fatal. 

Repair  of  Injury  to  the  Stomach. — Wound  of  the  stomach  should  be 

'Sajouss'  Annual  and  Analytical  Cyclopedia  of  Prac.  of  Medicine,  Vol.  I,  1899. 
2  Tillman's  Text-book  of  Surgery  (Tilton),  Vol.  Ill,  1898. 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  261 

closed  by  Lembert  suture  in  the  direction  of  blood  vessels.  If  the 
wound  is  large  the  Czerny-Lembert  suture  is  preferable.  Wounds  of  the 
posterior  wall  are  more  satisfactorily  reached  by  breaking  through  the 
gastro-colic  omentum.  When  the  wound  of  the  stomach  is  compli- 
cated by  injury  to  the  pancreas  posterior  drainage  through  the  skin 
of  the  lumbar  region  should  be  made. 

Wounds  01  the  Large  Intestine. — Gunshot  wounds  of  the  large 
bowel  covered  by  peritoneum,  except  those  of  the  transverse  colon,  are 
never  so  fatal  as  those  of  the  small  intestine.  This  was  true  of  gun- 
shot injuries  by  the  old  armanent  when  the  lesion  was  generally  more 
severe  than  that  inflicted  by  the  projectiles  of  the  present  day.  Otis 
records  fifty-nine  cases  of  spontaneous  recovery  from  gunshot  of  the 
cecum  and  ascending  colon,  the  descending  colon  and  sigmoid  flexure, 
and  a  few  instances  from  the  transverse  colon.  Nearly  all  the  cases 
were  complicated  by  fecal  fistula  which  closed  spontaneously  in  the 
large  majority  of  the  cases.  Forty-one  of  the  fifty  nine  cases  were  still 
living  after  the  lapse  of  twelve  years  or  more. 

The  more  hopeful  outcome  of  injury  to  this  part  of  the  intestine  is 
ascribed  to  the  fact  that  the  walls  of  the  gut  are  thicker  than  those  of 
the  small  intestine,  and  the  aperture  in  them  is  partially  closed  by  the 
greater  amount  of  tissue  involved  in  the  perforation.  In  addition  the 
gut  is  fixed  to  the  wall  of  the  abdomen  by  the  overlying  peritoneum,  it 
is  therefore  immobile,  extravasation  is  not  so  likely  to  occur;  and  again, 
the  contents  are  usually  more  solid.  It  may  be  stated  also  that  other 
organs  are  not  so  apt  to  be  implicated  in  antero-posterior  shots  which 
penetrate  in  the  line  of  the  ascending  and  descending  colons.  In  forty 
cases  in  the  Anglo-Boer  War  Stevenson  fixes  the  mortality  at  32.5  per 
cent.,  although  some  of  them  had  sustained  injury  to  the  liver,  bladder, 
and  kidney. 

Wounds  of  the  Sigmoid  Flexure  and  Rectum. — Wounds  of  the 
former  are  less  fatal  by  far  than  those  of  any  portion  of  the  intestinal 
tract.  Those  of  the  rectum  belong  to  the  hopeful  class,  when  uncom- 
plicated. They  are  often  complicated,  however,  by  shots  through  the 
bladder,  the  adjoining  pelvic  bones,  or  femur.  Such  shots  are  prone 
to  the  development  of  fecal  fistula,  cellulitis,  and  septicemia,  the  latter 
being  a  frequent  cause  of  death.  Stevenson  records  thirteen  cases  of 
gunshot  wound  of  the  sigmoid  flexure  and  rectum  in  the  Anglo-Boer 
War  with  a  mortality  of  30.7  per  cent. 

Treatment  of  Gunshot  Wounds  of  the  Rectum,  and  Colon  not 
Covered  by  Peritoneum. — Until  the  Anglo-Boer  War  gunshot  of  those 


262  GUNSHOT   WOUNDS 

parts  of  the  colon  extraperitoneally  located  were  supposed  to  be  at- 
tended with  less  danger  to  life  than  the  lesions  connected  with  the  peri- 
toneal cavity.  Mr.  Makins,  experience  is  decidedly  opposed  to  this 
idea.  He  saw  several  such  lesions  every  one  of  which  ended  fatallj^ 
and  likewise  he  found  that  extra-  as  compared  to  intraperitoneal 
wounds  of  the  bladder  were  also  more  fatal,  to  which  we  will  refer 
later.  Like  gunshot  of  the  rectum  the  indications  for  treatment  in 
colon  wounds  uncovered  by  peritoneum  are  the  relief  of  fistula,  cellu- 
litis, and  septicemia  which  result  from  extravasation  of  intestinal 
contents  into  the  tissues  outside  the  gut.  Whenever  practicable 
Mr.  Makins  enlarged  the  wounds  leading  to  the  colon  and  brought 
the  gut  to  the  surface.  The  artificial  opening  in  the  latter  was  at- 
tended to  later.  In  like  cases  Colonel  Stevenson  advises  the  introduc- 
tion of  1/2-inch  tube  as  far  as  the  opening  in  the  bowel.  Gauze  is 
packed  around  the  tube  to  prevent  the  intestinal  contents  from  con- 
taminating the  sides  of  the  wound.  In  such  cases  the  prime  indi- 
cation is  the  establishment  of  drainage,  and  either  method  when 
properly  carried  out  should  accomplish  this  end. 

In  wounds  of  the  rectum  colotomy  has  been  advised  and  prac- 
tised to  prevent  the  passage  of  feces  into  the  rectum.  Otis  calls 
attention  to  the  fact  that  the  older  surgeons  recommended  and  prac- 
tised division  of  the  anal  sphincters  to  prevent  extravasation  leading 
to  cellulitis  and  septicemia,  and  for  the  cure  of  fistulse  that  often  per- 
sist through  wounds  of  the  skin  in  adjoining  parts. 

Gunshot  Wounds  of  the  Liver  and  Gall  Bladder. — UncompH- 
cated  wounds  of  the  liver  from  small-caliber  bullets  recover  in  the  vast 
majority  of  cases.  When  complicated  by  hemorrhage  or  injury  to 
other  viscera  the  prognosis  is  not  so  good.  Hemorrhage  is  probably 
the  most  fatal  of  the  complications,  and  this  is  proportional  to  the  size 
of  the  wound  and  the  liability  to  injury  to  the  larger  vessels  in  the 
liver  substance.  Reporters  in  recent  wars  have  frequently  remarked 
upon  the  absence  of  wounds  showing  explosive  effects  in  the  liver  and 
other  viscera  in  hospital  cases.  Field  hospitals  are  not  the  place  to 
look  for  such  cases.  They  die  on  the  field  in  a  few  moments,  and 
never  live  long  enough  to  receive  hosptal  care. 

Wounds  of  the  liver  are  often  complicated  with  wounds  of  the 
thoracic  viscera,  stomach,  intestine  or  kidney.  The  more  serious 
complications  are  those  involving  the  thoracic  viscera  and  diaphragm. 
Such  cases  are  very  apt  to  die  from  pleural  septicemia.  Wounds  com- 
plicated by  injury  to  the  portal  vein  are  usually  rapidly  fatal.     Those 


GUNSHOT    WOUNDS    OF    THE    ABDOMEN  263 

complicating  the  gall  bladder  are  apt  to  cause  biliary  fistula,  and  the 
latter  is  most  frequently  seen  when  the  bullet  scores  the  surface  of  the 
organ  (Makins). 

The  symptoms,  aside  from  hemorrhage  in  a  certain  class  of  cases, 
are  not  typical.  One  has  to  be  guided  largely  by  the  location  of  the 
apertures  made  by  the  bullet.  Icterus  occurs  in  one-fifth  of  the 
cases  according  to  Edler.^  In  cases  with  extravasation  of  bile  in  the 
peritoneum,  there  is  icterus,  also  cholemia,  as  evidenced  by  pruritus, 
nausea  and  mental  hebetude.  Such  cases  are  rapidly  fatal  unless 
biliary  fistula  is  established  mth  free  drainage. 

In  the  Civil  War  Otis  records  fifty-nine  uncomplicated  gunshot 
wounds  of  the  liver  with  twenty-five  recoveries.  Stevenson  reports 
twenty-eight  cases  in  South  Africa  with  a  mortality  of  28.5  per  cent, 
and  Follenfant  gives  a  mortality  of  19.3  per  cent,  in  thirty-one  cases 
in  the  statistics  at  Kharbine  in  1904. 

Gunshot  wound  of  the  gall  bladder  is  rarely  referred  to  in  the 
literature,  a  fact  which  no  doubt  testifies  to  the  fatality  which  attends 
such  cases.  The  diagnosis  has  to  be  made  bj^  the  location  of  the  ex- 
ternal wounds,  the  occasional  flow  of  bile  externally,  and  active  re- 
action on  the  part  of  the  peritoneum.  The  diagnosis  is  no  more  than 
a  conjecture  until  the  peritoneum  has  been  opened. 

Otis  mentions  a  case  which  occurred  in  the  Civil  War  and  which 
ended  in  recovery.  The  ball  entered  on  the  right  side  near  the  carti- 
lage of  the  tenth  rib  3  or  4  inches  from  the  umbilicus,  and  escaped 
on  a  level  with  the  twelfth  dorsal  vertebra.  Seventeen  days  after 
the  injur}'-,  in  an  effort  to  sit  on  the  edge  of  his  bed,  there  was  a  sudden 
escape  of  about  1  pint  of  bile  from  the  wound  of  entrance.  For 
seventeen  daj^s  thereafter  about  a  pint  of  bile  continued .  to  escape 
daily  from  the  wound.  The  flow  was  greatest  between  the  hours  of 
3  and  6  p.  m.     The  stools  were  clayey,  there  was  distaste  for  food. 

Treatment. — Gunshot  of  the  liver  uncomplicated  by  hemorrhage 
recjuires  no  surgical  interference.  This  fact  is  prominently  empha- 
sized by  the  large  number  of  recoveries  of  gunshot  of  the  liver  in 
recent  campaigns.  Fischer  states  that  they  were  regarded  among  the 
slight  or  humane  wounds  bj^  some  of  the  surgeons  in  the  Manchurian 
campaign.  The  impossibility  of  excluding  complications  often  ren- 
ders exploratory  laparotomy  essential.  Hemorrhage  is  preferably 
controlled  by  a  narrow  gauze  packing,  the  end  of  which  should  be  left 
protruding  through   the   abdominal   wall.     In   larger   wounds   when 

i.^rchiv.  f.  klin.  Chirurg.,  Bd.  XIXIV,  Ch.  IV,  1887. 
18 


264  GUNSHOT   WOUNDS 

bleeding  still  continues,  the  best  way  to  control  the  hemorrhage  is  by 
packing  the  cavity  with  gauze,  or  when  practicable  the  sides  of  the 
wound  should  be  brought  together  by  suture.  A  straight  blunt 
needle  armed  with  number  3  or  4  cat-gut  is  preferable  for  the  purpose. 

When  the  gall  bladder  is  wounded  and  the  loss  of  substance  is 
extensive  colecystectomy  should  be  practised.  In  small  perforations 
the  wound  may  be  closed  by  silk  sutures  or  the  edges  of  the  perforation 
may  be  sewed  to  the  abdominal  wall  as  in  colecystectomy. 

The  following  case  bears  upon  the  wisdom  of  early  operation  and 
it  marks  one  of  the  triumphs  of  the  modern  method  of  treatment 
of  abdominal  wounds  when  the  surgeon  can  control  the  environments. 

First  Lieutenant  Clarence  E.  Fronk,^  Medical  Corps,  U.  S.  Army, 
reports  the  case  as  follows:  "A  Philippino  woman,  fifty  years  old,  was 
accidentally  shot  at  camp  McGrath,  P.  S.,  at  5.30  p.  m.,  Oct.  2,  1911, 
while  she  was  in  a  stooping  posture,  facing  the  gun  when  it  was  dis- 
charged. The  missile  was  a  32-caliber  slug  fired  from  a  No.  12  auto- 
matic shotgun.  She  was  examined  in  the  post  hospital  at  11  p.  m. 
when  the  following  condition  was  noted: 

''A  wound  about  1/8  inch  in  diameter,  1  1/2  inches  below  and  1 
inch  to  right  of  ensiform  cartilage.  No  wound  of  exit,  but  the  eleventh 
rib,  left  side,  was  fractured  at  its  center  and  the  missile  could  be  pal- 
pated just  under  the  skin  at  this  place.  The  wound  of  entrance  was 
enlarged,  and  by  exploring  with  the  finger,  its  entrance  into  the  peri- 
toneal cavity  was  confirmed.  The  woman  was  in  a  state  of  collapse, 
with  weak,  frequent  and  thready  pulse,  and  shallow,  rapid  respiration. 
Immediately  before  and  during  the  examination  she  vomited  a  large 
quantity  of  clotted  blood  mixed  with  stomach  contents. 

''The  case  clearly  demanded  surgical  intervention  and,  consent 
being  given  by  the  patient  and  relatives,  she  was  prepared  for  imme- 
diate laparotomy. 

''Sterilization  of  the  operative  area  was  accomplished  with  7  per 
cent,  tincture  of  iodine.  The  operation  was  begun  at  12.30  a.  m., 
Oct.  3,  1911,  under  chloroform  anesthesia,  it  not  being  thought  safe 
to  use  ether,  working  as  we  were  with  open  oil  lights. 

"An  incision  3  inches  long  was  made  through  the  left  rectus  muscle. 
Upon  incising  the  peritoneum,  the  abdominal  cavity  was  found  full 
of  fluid  blood  which  welled  up  from  the  region  of  the  gall  bladder.  The 
latter  was  located  abnormally  far  to  the  left;  it  being  directly  in  the 
line  of  incision.  The  transverse  colon  was  delivered  and  examined 
1  Military  Surgeon,  Vol.  XXX,  No.  6,  June,  1912. 


GUNSHOT   WOUNDS    OF   THE    ABDOMEN  265 

and  then  the  stomach.  No  wound  being  discovered  in  either  and  feel- 
ing certain  that  the  latter  had  been  perforated,  owing  to  the  patient 
having  vomited  a  large  amount  of  blood,  an  opening  was  made  in  the 
transverse  mesocolon  and  the  stomach  examined  posteriorly;  but  care- 
ful search  revealed  no  injury.  The  liver  and  gall  bladder  were  then 
examined  and  a  perforation  found  in  the  fundus  of  the  latter  from 
which  the  blood  was  flowing  freely.  This  wound  was  closed  with  a 
continuous  silk  suture,  reinforced  by  a  Lembert  suture,  which  effect- 
ively controlled  the  hemorrhage.  The  patient's  condition  being 
extremely  poor,  a  hasty  search  was  made  for  further  injury  to  the 
liver,  pancreas,  duodenum,  etc.,  but  none  was  found.  The  anesthetic 
was  stopped,  the  blood  mopped  out  with  dry  gauze,  a  quart  of  hot 
normal  saline  solution  poured  into  the  abdomen  and  the  wound  closed 
in  layers  without  drainage. 

"The  entire  operation  consumed  about  thirty  minutes.  Upon 
removal  from  the  table,  the  patient's  pulse  was  140  to  the  minute 
and  imperceptible  at  the  wrist.  She  was  placed  in  bed,  surrounded  by 
hot  water  bottles  and  given  1000  c.c.  of  normal  saline  solution  into  the 
median  basilic  vein,  to  which  she  responded  promptly.  Salt  solution 
per  rectum  by  Murphy's  method  was  begun  and  continued  during  the 
following  twenty-four  hours,  taking  in  all  about  3000  c.c.  Con- 
valescence was  rapid  and  uneventful,  the  wound  healing  by  primary 
union. 

"The  missile  was  removed  at  the  end  of  two  weeks  and  proved 
to  be  an  irregular  shaped  'slug'  about  .32  inch  in  caliber. 

"The  peculiar  features  of  this  case  are: 

"(A)  The  large  amount  of  blood  vomited  with  no  injury  to  the 
stomach,  the  bleeding  being  from  the  cystic  artery  into  the  gall  bladder 
and  then  into  the  stomach  by  way  of  the  cystic  and  common  ducts 
and  duodenum. 

"  (B)  The  possibility  of  a  missile  of  such  a  size  passing  through 
this  region  with  no  injuries  discoverable  in  the  other  organs  and  the 
excessive  hemorrhage  from  the  gall  bladder  wound."  The  patient's 
recovery  was  uninterrupted. 

Gunshot  Wounds  of  the  Pancreas. — Wounds  of  this  organ  have 
not  been  frequently  noted  in  the  literature.  They  are  usually  attended 
with  primary  hemorrhage  and  death  occurs  early.  Its  intimate  rela- 
tion with  other  viscera  like  the  spleen,  liver,  stomach,  duodenum,  the 
large  vessels  and  the  spinal  column,  makes  wounds  of  the  pancreas  very 
fatal  on  the  field  or  soon  after  receipt  of  the  injury.     Otis  refers  to 


266  GUNSHOT   WOUNDS 

five  cases  occurring  in  the  Civil  War.  "In  one  of  the  cases  the  ball 
entered  the  right  side  below  the  ribs  and  emerged  on  the  left  side." 
Two  days  later  part  of  the  pancreas  the  size  of  an  egg  protruded  from 
one  of  the  wounds.  The  pedicle  of  the  tumor  was  strangulated  by 
means  of  a  silver  wire  and  subsequently  cut  through  with  scissors. 
No  dangerous  symptoms  transpired  and  the  patient  was  up  and  moving 
about  the  hospital  at  the  end  of  five  weeks.  Three  of  the  five  cases 
reported  by  Otis  lived  from  twelve  to  fifteen  days.  The  causes  of 
death  in  four  of  the  fatal  cases  were  shock  and  peritonitis  in  one,  and 
secondary  hemorrhage  in  the  other  three.  In  four  of  the  cases  the 
bullet  entered  behind  and  coursed  transversely  through  the  body. 
In  one  case  the  ball  entered  anteriorly  near  the  end  of  the  ensiform 
cartilage  with  probable  involvement  of  the  stomach.  In  three  of  the 
cases  the  diagnosis  was  not  made  until  post-mortem.  The  autopsies 
gave  but  little  to  note  on  the  morbid  anatomy  and  the  clinical  his- 
tories pointed  to  no  special  symptoms  referable  to  traumatism  of  the 
pancreas. 

Treatment  of  Gunshot  of  the  Pancreas. — The  surgical  indications 
in  all  wounds  of  the  pancreas  are :  arrest  of  hemorrhage  and  establish- 
ment of  drainage.  The  former  is  to  be  controlled  by  suture  when 
possible,  otherwise  by  tampon.  Lumbar  drainage  is  always  preferable. 
In  twelve  cases^  of  gunshot  of  the  pancreas  reported  by  Von  Mikulicz- 
Radecki  laparotomy  was  done  in  five  cases  with  three  recoveries.  The 
seven  cases  not  operated  upon  died. 

Gunshot  Wounds  of  the  Spleen. — Wounds  of  this  organ  are  prone 
to  hemorrhage  from  the  extreme  vascularity  and  friable  nature  of  the 
tissues.  The  prognosis  is  further  hampered  by  accompanying  wounds  of 
other  organs  like  the  left  kidney,  the  stomach,  diaphragm,  pleura,  lungs 
and  other  viscera.  The  diagnosis  usually  rests  upon  a  study  of  the 
bullet's  track.  Four  cases  were  diagnosed  in  the  Anglo-Boer  War  with 
one  recovery  (Stevenson).  The  fact  that  wounds  of  the  spleen  are  rare 
in  the  literature  suggests  their  extreme  fatality.  Makins  points  to  a 
case  in  South  Africa  complicated  by  renal  injury.  At  time  of  death 
three  weeks  later,  the  wound  in  the  spleen  had  cicatrized.  The  same 
author  is  of  the  opinion  that  wounds  of  the  spleen  from  reduced-caliber 
bullets  are  seldom  accompanied  by  hemorrhage  since  he  never  saw  a 
case  with  dullness  in  the  flanks  to  indicate  the  presence  of  internal 
hemorrhage.  In  the  cases  he  saw  the  diagnosis  was  made  by  the  loca- 
tion of  the  external  wounds  and  the  bullet-track  so  that  the  element 
^  Annals  of  Surgery,  July,  1903. 


GUNSHOT   WOUNDS    OF   THE   ABDOMEN  267 

of  mistaken  diagnosis  has  to  be  considered.  Follenfant  gives  one  death 
in  seven  cases  out  of  the  Kharbine  statistics  for  1904. 

Treatment. — The  surgical  inchcations  are  control  of  hemorrhage 
and  when  this  is  copious  the  abdomen  needs  to  be  opened  promptly. 
When  the  bleeding  cannot  be  controlled  by  suture,  splenectomy  is  to 
be  resorted  to. 

Gunshot  Wounds  of  the  Kidney. — Uncomplicated  kidney  wounds 
by  gunshot  rarely  occur.  The  spleen,  intestine,  stomach,  or  colon  is 
usually  involved.  The  lesion  may  or  may  not  involve  the  peritoneum. 
Wounds  of  the  peripheral  part  of  the  organ,  near  the  extremities  or 
convex  border,  offer  a  better  prognosis  than  those  near  the  central  part. 
If  the  pelvis  of  the  kidney  is  implicated,  the  prognosis  is  bad,  because 
escape  of  blood  and  urine  in  the  peritoneal  cavity  are  prone  to  set  up 
infection.  Extraperitoneal  tracks  implicating  the  pelvis  or  hilum  of 
the  kidney  are  apt  to  end  in  perinephritic  abscess  from  extravasation 
of  urine  in  the  surrounding  tissues.  Urinary  fistula  is  one  of  the 
sequelae  of  such  cases.  Fistula  persists  a  long  time,  but  eventually 
closes  spontaneously. 

With  the  use  of  the  old  armament  the  amount  of  tissue  laceration 
was  great  and  the  fatality  was  in  keeping  with  the  amount  of  lesion. 
Otis  reports  seventy-eight  cases  in  the  Civil  War  with  a  mortality  of 
66.2  per  cent.  Wounds  of  the  kidney  by  the  reduced-caliber  bullet 
in  recent  wars  have  not  been  so  fatal,  especially  when  the  bullet  has 
traversed  the  extremities  or  convex  border  of  the  organ,  away  from 
the  pelvis  and  hilum.  At  the  mid  ranges  the  bullet  makes  a  clean  per- 
foration which  shows  a  tendency  to  heal  in  a  few  days,  without  serious 
symptoms.^  Stevenson  reports  thirteen  cases  of  wound  of  the  kidney 
out  of  207  gunshot  wounds  of  the  abdomen,  with  two  deaths.  Only 
two  of  the  cases  were  uncomplicated.  The  other  organs  involved  were 
the  spleen  1,  stomach  2,  large  intestine  1,  lung  2,  liver  1.  Such  a  small 
mortality,  15.3  per  cent.,  speaks  well  for  the  prognosis  after  wounds  of 
the  kidney  and  other  organs  as  well. 

The  mortality  of  the  uncomplicated  cases  is  still  lower,  but  we  must 
remember  that  the  greater  penetration  of  the  new  projectile  has  a 
tendency  to  increase  the  percentage  of  complicated  wounds  and  that 
associatedinjuriesof  the  lungs,  spine,  liver,  etc.,  are  far  more  common 
than  formerly. 

Injury  by  shrapnell  balls  and  pieces  of  shell  are  prone  to  hemorrhage 
and  also  sepsis,  in  spite  of  the  improvement  in  wound  treatment,  and 
^  Makins,  op.  cit. 


268  GUNSHOT   WOUNDS 

the  mortality  is  but  a  trifle  less  than  formerly^  for  wounds  from  this 
source. 

Symptoms. — Pain  and  hematuria  are  the  two  symptoms  which 
specially  indicate  renal  perforation.  The  pain  usually  rachates  down- 
ward extending  to  the  genitals  and  thighs,  and  a  desire  to  urinate  and 
retraction  of  the  testicle  are  present.  Hematuria  is  present  in  per- 
forating wound  of  any  part  of  the  kidney.  It  is  only  absent  in  cases 
which  have  suffered  division  of  the  ureter  or  those  cases  where  blood 
accumulates  in  the  pelvis  of  the  kidney  from  which  the  ureter  is 
occluded.  Only  clear  urine  from  the  other  kidney  will  then  reach 
the  bladder.  In  certain  cases  with  extensive  lesion  there  may  be 
suspended  excretion  of  the  kidney  with  absence  of  hematuria. 

Treatment. — Wound  of  the  kidney  generally  calls  for  abdomnial 
section  because  the  lesion  is  so  often  complicated  by  injury  to  other 
organs.  When  the  bullet  has  severed  the  renal  vessels  or  committed 
great  destruction  of  kidney  tissue  nephrectomy  is  demanded.  As  un- 
complicated injuries  by  the  modern  rifle  bullet,  wounds  of  the  kidney 
heal  rapidl}'-  "^dthout  serious  symptoms  beyond  transient  hematuira 
(]\Iakins) .  The  treatment  in  such  cases  is  rest  and  the  administration 
of  opium  when  hematuria  is  pronounced.  Wound  of  the  pelvis  or 
ureter  demands  nephrotomy  in  order  to  establish  temporarj^  drainage 
for  the  urine.  If  the  wound  is  in  the  loin,  free  drainage  by  enlarging 
the  wound  should  be  practised  to  prevent  cellulitis  and  septicemia  from 
extravasated  urine.  If  hydronephrosis  develops  it  should  be  relieved 
by  incision  and  drainage. 

The  following  case  of  complicated  gunshot  wound  of  the  kidney 
treated  expectantly  on  account  of  the  unfavorable  conditions  in  active 
campaign  shows  the  chance  of  recovery  from  gunshot  by  the  new  mili- 
tary rifle  bullet.  Major  T.  T.  Knox,  1st  U.  S.  Cavalry,  was  shot  on 
June  25,  during  the  advance  on  Santiago  de  Cuba.  A  Mauser  bullet 
entered  the  back  on  the  right  side  and  ranging  forward  emerged  through 
the  skin  opposite  the  ninth  and  tenth  ribs.  He  was  seen  five  hours 
later  by  Doctor  W.  E.  Parker,  who  expressed  the  opinion  that  the  ball 
had  penetrated  the  kidney  and  liver.  His  pulse  was  130,  "he  was  in 
a  cold  clammy  sweat  and  his  urine  was  full  of  blood  ....  His  con- 
dition was  such  that  he  would  have  died  on  the  table  had  he  been  sub- 
jected to  laparotomy.  He  was  given  strj^chnia  and  atropin  under 
the  skin  ever}'-  three  hours.  At  the  end  of  twent3^-four  hours  tympa- 
nites developed  which  disappeared  after  a  full  dose  of  magnesia  sul- 

1  Graf  and  Hildebrandt,  op.  cit. 


GUNSHOT    WOUXDS    OF    THE    .\BDOMEN  269 

phate.  The  blood  in  the  urine  gradually  disappeared  and  the  officer 
was  eventually  restored  to  full  duty." 

Gunshot  Wound  of  the  Adrenal  Gland. — Injury  to  this  organ  by 
gunshot  is  necessarily  rare  on  account  of  its  diminutive  size  as  compared 
to  other  organs  in  the  body.  Otis  makes  reference  to  but  one  case  dur- 
ing the  Civil  War.  The  ball,  after  fracturing  the  ninth  rib,  penetrating 
the  left  lung  and  diaphragm,  lodged  in  the  left  suprarenal  gland.  The 
man  died  four  weeks  later  of  pj'emia.  There  was  a  marked  icteroid 
discoloration  which  it  was  considered  might  have  been  the  result  of 
pigment  deposit  after  the  bronzing  described  by  AclcUson.  The  sug- 
gestion is  of  value  in  the  study  of  future  cases. 

Treatment. — Xo  treatment  of  a  surgical  nature  is  indicated  for  in- 
jury to  the  gland  itself. 

Wounds  of  the  Urinary  Bladder. — Gunshot  wounds  of  this  viscus 
were  classed  among  dangerous  wounds  in  the  days  of  the  old  armament. 
The  mortality  was  63  per  cent,  in  the  Franco-German  War,  1870-71. 
Otis  refers  to  183  recorded  cases  in  the  Ci\dl  War  mth  a  mortality  of 
54.0  per  cent.  The  majority  of  those  who  recovered  the  immediate 
effects  of  the  battle  injury  ''suffered  from  grave  disabilities,  and  many 
from  distressing  infirmities."  Much  of  the  protracted  suffering  was  the 
result  of  fistules  from  necrosis  of  the  pelvic  bones;  rectovesical  fistulse 
and  stone  in  the  bladder  as  a  result  of  lodgment  of  foreign  bodies  in  the 
cavity  of  the  organ,  such  as  the  projectile  itself  or  fragments  thereof, 
fragments  of  bone,  bits  of  clothing,  hair,  particles  of  integument,  and 
splinters  of  wood.  Our  present  methods  of  wound  treatment  can  now 
forestall  the  majority  of  the  complications  and  disabilities  mentioned. 
This,  \\dth  the  beneficence  which  comes  from  the  use  of  the  reduced- 
caliber  projectiles,  has  demonstrated  that  we  may  expect  a  favorable 
prognosis  in  the  large  majority  of  bladder  wounds  in  the  wars  of  the 
future.  Mr.  Makins  has  called  our  attention  to  the  outcome  of  extra- 
peritoneal as  compared  to  intra-peritoneal  wounds.  In  the  former 
there  is  greater  tendency  to  complications  as  a  result  of  suppurative 
cellulitis  and  septicemia,  complications  that  require  active  surgical 
interference.  Intraperitoneal  perforations  exhibit  less  clanger  pro- 
vided the  urine  is  of  normal  character. 

The  character  of  the  wound  and  the  prognosis  are  verj-  much 
influenced  if  the  bladder  is  full  or  empty  at  the  moment  of  impact.  In 
the  latter  condition  the  small  jacketed  bullet  makes  a  channel  w^hich  is 
soon  closed  by  the  contractile  tissue  of  the  viscus.  If,  however,  the 
bladder  is  full  the  contents  escape  through  the  perforations  and  the 


270  GUNSHOT   WOUNDS 

accumulating  urine  continues  to  escape.  Makins  noticed  that  un- 
complicated peritoneal  wounds  of  the  bladder  recovered  spontaneously 
in  a  considerable  proportion  of  the  cases,  but  extra-peritoneal  perfora- 
tions were  more  apt  to  end  in  troublesome  complications,  while  all 
wounds  at  the  base  of  the  bladder  died,  in  his  experience. 

The  superior  penetration  of  the  new  armament  has  added  to  the 
number  of  associated  wounds  that  attend  injury  to  the  urinary  bladder. 
The  bones  of  the  pelvis,  the  hip-joint,  adjoining  vessels  and  nerves,  the 
peritoneal  cavity  and  its  different  viscera,  the  ureters,  kidneys,  genitals, 
and  rectum  are  often  implicated.  The  order  of  frequency  of  wounds  of 
adjoining  parts  is  as  follows:  bones  of  the  pelvis,  intestines,  rectum, 
large  blood-vessels,  genitals,  large  nerves,  kidneys,  ureters. 

Stevenson  notes  seventeen  cases  in  the  Anglo-Boer  War  with  three 
deaths.  Two  of  the  cases  passed  the  bullet  per  urethram.  Follenfant 
gives  a  mortality  of  29.2  per  cent,  out  of  fourteen  cases  in  the  Kharbine 
statistics  for  1904. 

Symptoms. — Hemorrhage  and  an  empty  bladder  are  the  two  prin- 
cipal symptoms.  The  latter  is  generally  associated  with  intra-perito- 
neal  wounds,  the  urine  escaping  into  the  peritoneal  cavity,  while  hemor- 
rhage in  the  organ  is  most  generally  associated  with  extra-peritoneal 
injury.  The  latter  are  apt  to  show  signs  of  inflammation  from  extra- 
vasation of  urine  and  later  fistula  from  which  urine  dribbles.  Wounds 
implicating  the  bladder  and  rectum  are  apt  to  end  in  vesicorectal  fistula 
with  escape  of  urine  per  rectum,  or  feces  and  gas  may  escape  per  ure- 
thram. The  appearance  of  blood  in  the  urine  is  one  of  the  early  symp- 
toms of  gunshot  wound  of  the  bladder.  The  bladder  is  sometimes  filled 
with  blood  clots  which  cause  retention  and  infection  unless  promptly 
relieved.  Abnormal  urine  escaping  in  the  peritoneal  cavity  will  set 
up  peritonitis  very  promptlj^.  The  course  of  the  ball  will  often  indi- 
cate injury  to  the  viscus.  The  bullet's  track  is  generally  disposed 
antero-posteriorly  through  or  just  above  the  pelvis,  but  more  often  it 
enters  one  groin  and  ranging  downward  and  backward  it  makes  its 
exit  through  the  opposite  buttock.  Shots  implicating  the  bladder  are 
also  disposed  transversely  just  behind  the  symphysis  pubis. 

Treatment. — The  surgical  indications  differ  in  accordance  with 
the  character  of  the  wound.  Intraperitoneal  wounds  of  the  bladder 
demand  laparotomy  in  all  cases  in  which  the  environments  are  favor- 
able for  operation.  Early  laparotomy  favors  recovery  in  nearly  all 
uncomplicated  bladder  wounds.  As  a  matter  of  precaution  the 
urethra  should  be  cleansed  by  irrigation  with  a  mild  antiseptic  solu- 


GUNSHOT   WOUNDS    OF   THE    ABDOMEN  271 

tion  after  which  a  sterile  catheter  is  introcluced  as  far  as  the  bladder 
and  secured  in  place.  This  is  done  to  distend  the  bladder  in  order 
to  bring  the  perforation  into  view  if  necessary,  and  to  drain  the  viscus 
in  the  after  treatment. 

The  perforation  in  the  bladder  is  brought  together  by  a  deep  and 
superficial  line  of  sutures.  Urethral  siphonage  is  maintained  for 
forty-eight  to  seventy-two  hours  subsequently.  We  should  much 
prefer  to  maintain  drainage  through  a  perineal  section  in  the  regular 
way  as  practised  after  urethral  and  bladder  operations  for  other  causes. 
The  difficulty  of  keeping  a  catheter  in  place  in  field  conditions  espe- 
cially is  very  great.  When  the  environments  are  such  in  field  practice 
that  laparotomy  is  contraindicated,  we  should  recommend  perineal 
drainage,  an  operation  which  is  easily  and  quickly  done,  as  the  best 
means  of  keeping  the  bladder  free  of  urine.  In  gunshot  from  reduced- 
caliber  bullets  where  the  tendency  to  leakage  of  urine  into  the  peri- 
toneal cavity  is  not  marked  external  perineal  urethrotomy  would 
establish  an  additional  precaution  against  extravasation. 

Extraperitoneal  wounds  of  the  urinary  bladder  are  best  treated 
by  keeping  the  bladder  empty.  If  the  external  wound  cannot  be 
readily  drained,  the  latter  should  be  accomplished  by  a  suprapubic 
cystotomy  or  a  perineal  section  and  for  field  conditions,  preferably 
the  latter. 

GUNSHOT  WOUNDS  OF  THE  EXTERNAL  GENITAL  ORGANS 

Wounds  of  the  genitals  by  gunshot  form  a  comparatively  small 
group  of  the  wounds  in  war.  They  were  never  considered  dangerous 
in  themselves  when  inflicted  by  the  old  armament,  and  they  are  very 
much  less  so  now. 

The  wounds  of  this  class  include  the  anatomical  parts  concerned, 
viz.,  the  penis,  urethra,  testicles  and  vas  deferens. 

Wounds  of  the  Penis. — Otis  reported  309  cases  from  the  Civil 
War  with  a  mortality  of  13.2  per  cent.,  principally  due  to  grave 
complications  and  injuries  received  elsewhere,  as  gunshot  fracture 
of  the  pelvis  and  femur.  Some  of  the  less  complicated  cases  succumbed 
to  diseases  hke  small-pox,  tetanus,  pneumonia,  etc. 

Notwithstanding  the  large-caliber  bullets  of  that  day,  Otis  mentions 
five  cases  of  lodged  balls  in  the  penis,  one  of  the  missiles  was  conoidal 
in  shape  and  weighed  838  grains  when  it  was  removed  from  the  root 
of  the  organ,  Fig.  123. 


272 


GUNSHOT   WOUNDS 


The  severity  of  these  wounds  is  necessarilj^  less  with  the  smaller 
calibers.  The  wounds  of  the  skin  and  erectile  tissue  are  of  smaller 
diameter  than  the  projectile.  Contrarj^  to  what  might  be  expected 
hemorrhage  is  not  frequent  in  cases  of  injury  to  the  large  vessels 
supplying  the  penis.  Hematomata  of  varying  sizes  and  extent  are 
frequent.  Schaeffer  mentions  a  case  in  which  the  bullet  penetrated 
the  glans  and  infiladed  the  penis  posteriorly  to  the  bladder  when  the 

former  was  apparentlj^  in  a  state  of 
erection.  The  more  frequent  wounds, 
however,  are  directed  antero-posteriorly 
or  vice  versa.  In  some  cases  the  ball 
enters  the  neighborhood  of  the  pubis 
and  emerges  behind  the  scrotum  while 
other  shots  are  disposed  transversely. 
The  lesion  may  consist  of  a  furrow,  or 
complete  perforation,  while  wounds 
from  shell  fragments  have  been  known 
to  produce  entire  ablation  of  the  penis. 
Wounds  of  the  Urethra. — The  more 
important  wounds  of  the  penis  are  those 
which  include  lesion  of  the  urethra. 
Otis  reported  105  cases  in  the  Civil  War 
with  twenty-two  deaths.  The  fatali- 
ties like  those  of  the  penis  proper  were 
often  due  to  severe  complications  in 
adjoining  anatomical  structures.  The  uncomplicated  cases  were 
fatal  from  "exhaustion,"  "urinary  infiltration,"  "phlebitis,"  "dry 
gangrene,"  etc.,  causes  that  are  more  often  preventable  under  present 
modes  of  treatment. 

The  amount  of  lesion  to  the  urethra  from  the  military  rifle  bullet 
is  not  so  extensive.  The  canal  may  be  only  partially,  or  it  may  be 
entirel}^  cut  across. 

The  indications  are  to  prevent  extravasation  of  urine  in  the  sur- 
rounding tissues  which  is  apt  to  result  from  mechanical  impediment 
to  the  free  flow  of  urine.  When  practicable  the  opening  in  the  ure- 
thra should  be  located  and  a  soft  catheter  should  be  passed  through 
the  opening  into  the  urethra  as  far  as  the  bladder.  If  the  flow  is 
impeded  and  retention  takes  place,  suprapubic  aspiration  or  incision 
should  be  practised  after  which  the  patencj^  of  the  urethral  outlet 
should  be  established.     Drainage  is  the  prime  indication  andwhen- 


FiG.  123. — Ball  excised  from  the 
penis.  Spec.  3146  1.  Army  Medical 
Miiseum  collection. 


GUNSHOT    WOUNDS    OF    THE    .IBDOMEN  273 

ever  necessary  perineal  section  should  be  clone.  Wounds  of  the 
urethra  from  the  reduced-caliber  bullets  in  recent  wars  are  said  to 
heal  readily  with,  few  complications.  The  occurrence  of  urethral 
fistula  is  treated  in  the  usual  way. 

"Wounds  of  the  Testicles. — Otis  records  586  gunshot  wounds  of  the 
testicle  with  a  mortality  of  11.2  per  cent.  The  majority'  consisted  of 
lacerated  wounds  of  one  or  both  testes  with  accompanying  wounds  of 
neighboring  parts  like  the  penis,  thighs,  perineum,  pelvis.  The 
deaths  were  mostly  due  to  the  complicating  wounds. 

Wounds  of  the  testes  are  naturally  influenced  by  the  size  of  the 
projectile  and  consequently  wounds  of  the  testicle  and  scrotum  by  the 
reduced  caliber  jacketed  bullet  exhibit  small  perforations,  which  heal 
readily. 

Injury  to  the  testicle  is  attended  with  more  or  less  shock,  vomiting 
and  pain  radiating  into  the  abdomen.  Hematoma  in  the  scrotum  is 
not  uncommon.  Should  infection  result  it  ma}"  extend  to  the  tunica 
vaginalis  and  testicle  Tvith  resulting  suppuration. 

Treatment  of  wounds  of  the  testicle  consists  in  a  clean  dressing  and 
conservative  management  unless  suppuration  supervenes  when  free 
drainage  should  be  established,  but  removal  of  the  organ  in  the  major- 
ity of  the  cases  wdth  suppuration  becomes  necessar3^  In  cases  exhib- 
iting considerable  laceration  of  the  testicle  castration  should  be 
practised. 

Wounds  of  the  Spermatic  Cord. — This  class  of  wounds  is  very 
rare.  They  usually  consist  of  contusions,  transverse  or  oblique 
wounds.  Otis  records  thirty-two  cases  with  two  deaths.  The  pub- 
lished reports  from  recent  wars  make  but  few  references  to  gunshot  of 
the  cord. 

Hematocele  and  sanguinous  infiltration  are  usually  present  with 
the  immediate  symptoms.  Among  the  secjuelse,  atrophy  of  the  tes- 
ticle sometimes  occurs  from  injury  to  the  vas,  and  Otis  relates  a  case 
in  which  semen  escaped  from  a  fistule  located  near  the  tuberosity  of 
the  ischium  for  some  time. 

The  treatment  of  gunshot  of  the  cord  consists  in  arrest  of  hemor- 
rhage and  a  clean  dressing. 

Wounds  of  the  Scrotum. — Gunshot  wounds  of  the  scrotum  are 
seldom  attended  with  much  pain  or  danger.  The  contractile  fibers 
of  the  dartos  close  the  wounds  so  reacUly  that  wounds  by  reduced-cali- 
ber bullets  are  sometimes  overlooked.  This  was  particularly  notice- 
able in  two  cases  at  Santiago.     Otis  mentions  several  cases  of  lodged 


274  GUNSHOT   WOUNDS 

balls  in  the  scrotum,  the  missiles  having  made  their  way  thither  from 
distant  parts. 

The  treatment  consists  in  strict  antiseptic  management  because  of 
the  tendency  to  infection.  The  appearance  of  the  latter  calls  for 
free  incisions  and  thorough  drainage. 


CHAPTER  X 

Injuries  to  Blood-vessels  and  the  Nature  of  their  Lesions; 
Results  of  Injury  to  the  Blood-vessels;  Traumatic  Aneu- 
rysms; Aneurysmal  Varex  and  Varicose  (Arterio-venous) 
Aneurysm;  Injury  to  Peripheral  Nerves. 

Injury  to  blood-vessels  as  pointed  out  while  referring  to  hemorrhage 
as  a  sjonptom  of  gunshot  wounds  has  changed  as  to  frequency,  and  also 
as  to  the  nature  of  the  lesion,  with  the  change  of  armament.  The 
vessels  were  wont  to  evade  the  pressure  exerted  by  the  low  velocity 
round  lead  bullets  of  the  old  armament.  As  greater  velocity  was 
conferred  on  the  projectiles,  and  as  their  shape  became  elongated,  the 
tendency  to  escape  injury  on  the  part  of  the  vessels  was  not  so  marked. 
The  change  that  brought  about  the  most  characteristic  results  was 
coincident  Avith  the  use  of  reduced-caliber  bullets.  The  latter  pass 
through  the  tissues  so  rapidly  when  animated  by  their  greater  velocity 
that  the  vessels  have  no  time  to  be  pushed  aside.  They  either  suffer 
(a)  contusion,  (b)  partial  or  (c)  complete  division. 

(a)  Contusion  of  an  artery  includes  any  degree  of  injury  which 
does  not  open  the  lumen.  A  contusion  may  consist  of  a  slight  trau- 
matism involving  laceration  of  tissues  in  the  coats  of  the  vessel  with 
escape  of  blood  from  capillaries  that  infiltrate  surrounding  tissues,  or  the 
injury  may  be  more  severe,  ending  in  necrosis  of  the  coats  of  the  vessel 
later.  Bullets  or  larger  missiles,  moving  at  low  velocity,  when  strik- 
ing at  a  tangent,  may  cause  laceration  of  the  inner  and  middle  coats  of 
the  vessel,  without  injury  to  the  outer  coat.  Injury  of  a  minor  kind 
will  heal  without  subsequent  symptoms  as  a  rule,  or  there  may  follow 
a  thrombosis,  at  the  point  of  impact,  leading  to  obliteration  of  the 
lumen. 

In  severe  contusion  necrosis  of  the  damaged  part  of  the  vessel  may 
end  in  rupture,  an  occurrence  which  is  common  when  sepsis  has  gained 
access  to  the  injured  part.  In  that  event  secondary  hemorrhage  will 
take  place  in  ten  to  fifteen  days  from  the  receipt  of  the  injury.  Again, 
as  a  consequence  of  the  lesion  stated,  a  traumatic  aneurysm  may 
appear. 

275 


276  GUNSHOT   WOUNDS 

Among  the  ultimate  or  later  effects  of  injury  to  neighboring  tissues, 
a  vessel  may  suffer  contraction  by  pressure  or  traction  from  scar  tissue. 
The  volume  of  the  pulse  below  the  seat  of  injury  may  thereby  be  per- 
ceptibly diminished,  or  an  audible  murmur  may  be  found  at  the  point 
where  the  vessel  is  compressed. 

(b)  Partial  division  of  an  artery  may  occur  from  a  displaced  splinter 
of  bone,  a  fragment  of  shell,  a  deformed  bullet  with  sharp  angles,  or 
fragments  thereof.  The  high-velocity  small-bore  bullet  may  cut 
away  a  notch  in  a  vessel  by  striking  it  on  the  side,  or  in  the  case  of 
vessels  larger  than  its  own  cahber  when  it  makes  a  regular  impact  in 
the  middle  of  the  vessel  it  inflicts  two  circular  openings  in  the  opposite 
walls  of  the  vessel. 

(c)  Complete  division  of  an  artery  is  followed  by  loss  of  pulsation 
in  the  distal  portion  of  the  vessel  if  the  collateral  circulation  is  deficient. 
If  anastomosis  is  free  it  will  reappear  later. 

Wounds  of  veins  are  met  wdth,  and  they  are  very  similar  to  those 
of  arteries. 

The  results  of  injury  to  vessels  are  thrombosis  and  obhteration, 
and  the  various  forms  of  hemorrhage  to  which  we  have  already  re- 
ferred. There  now  remain  for  consideration,  traumatic  aneurysms, 
and  arteriovenous  aneurysms. 

Traumatic  Aneurysms. — Aneurysms  as  a  result  of  trauma  from 
gunshot  have  a  far-reaching  importance  to-day  as  compared  to  former 
times.  As  example,  we  may  state  that  before  the  Spanish-American 
and  Anglo-Boer  Wars,  traumatic  aneurysms  of  the  arterio-venous  type 
were  mostly  seen  in  civil  hospitals  from  stab  wounds,  injuries  by 
machinery,  and  as  a  result  of  accident  from  the  operation  of  venesec- 
tion at  the  bend  of  the  elbow  in  the  days  of  blood  letting.  The  expe- 
rience of  recent  campaigns  brings  out  the  fact  that  surgeons  now  look 
to  military  instead  of  civil  practice  for  the  study  of  all  forms  of  trau- 
matic aneurysm,  and  that  what  was  once  a  comparatively  unknown 
trauma  in  military  practice  has  become  one  of  the  distinct  features  of 
war  wounds  by  the  new  armament. 

Aneurysm  as  a  result  of  trauma  by  gunshot  occurred  in  seventy- 
four  cases  in  the  Civil  War  and  forty-four  cases  in  the  Franco-German 
War,  its  appearance  being  one  case  for  every  2000  wounded  in  the 
latter.  While  these  figures  represent  the  frequency  of  occurrence  in 
former  campaigns,  a  single  observer  in  the  Boer  War  like  Graf  found 
4  per  cent,  of  his  wounded  suffering  from  some  form  of  traumatic 
aneurysm. 


INJURY   TO   BLOOD-VESSELS   AND    NATURE    OF   THE   LESIONS        277 

The  frequencj^  of  blood-vessel  injuries  was  apparent  to  us  at  San- 
tiago where  out  of  1400  wounded  we  observed  five  cases  of  gangrene  as 
a  result  of  vessel  injuries  which  required  amputation,  one  injury  to  the 
subclavian  artery,  two  cases  of  ligation  of  the  brachial  and  two  of  the 
femoral  for  diffuse  aneurysm,  and  one  case  of  arterio- venous  communica- 
tion between  the  femoral  artery  and  vein. 

Follenfant  relates  that  the  Russian  Surgeon  Bornhaupt  out  of 
3600  wounded  at  Karbine  operated  five  times  on  vessels  of  the  extrem- 
ities for  aneurysm,  nine  times  for  arterio -venous  communications  and 
that  there  were  four  cases  of  aneurysms  cured  following  a  period  of 
rest. 

Two  varieties  of  traumatic  aneurysm  are  recognized,  viz.,  the 
diffuse  and  the  circumscribed. 

Diffuse  traumatic  aneurysm  is  due  to  persistent  hemorrhage  from 
an  artery.  The  blood  is  effused  into  the  surrounding  tissues  and  the 
resulting  lesion  is  more  properly  speaking  a  hematoma.  This  form  of 
aneurysm,  and  the  circumscribed  variety  also,  are  very  common  as  a 
result  of  wounds  from  the  reduced-caliber  projectiles.  They  do  not 
result  so  frequently  from  lead  bullets,  unless  the  latter  have  acquired 
a  cutting  edge  from  deformation.  We  stated  under  the  subject  of 
hemorrhage  in  the  chapter  on  the  Symptoms  of  Gunshot  Wounds  that 
free  external  hemorrhage  was  not  of  frequent  occurrence  with  lesion 
of  the  larger  vessels  of  the  extremities  and  neck,  because  of  the  narrow 
track  of  the  modern  bullet.  The  narrow  track  is  readily  closed  by  a 
change  of  alignment  of  the  apertures  in  the  different  layers  of  muscle, 
intermuscular  septa  and  other  soft  parts.  The  occluded  track  arrests 
the  external  hemorrhage  which  would  otherwise  occur,  and  the  result 
is  free  bleeding  in  the  tissues  which  are  dissected  by  the  blood  pressure 
causing  considerable  tension,  interference  to  the  venous  circulation, 
and  rise  of  temperature  from  absorption  of  fibrin  ferment.  Discolora- 
tion is  present  if  the  blood  is  near  the  surface.  There  may  be  fluctua- 
tion, loss  of  pulse  and  edema. 

The  hemorrhage  generally  continues  from  the  time  of  injury,  but 
the  symptoms  attending  its  presence  are  not  manifest  for  some  days. 
When  a  bullet  has  grazed  an  artery  the  remaining  coats  may  not  give 
way  at  once.  In  such  a  case  the  appearance  of  the  aneurysm  will  not 
show  itself  under  ten  days  to  three  weeks. 

Treatment. — The  indications  for  treatment  of  this  form  of  traumatic 
aneurysm  are  similar  to  those  for  external  primary  hemorrhage.  In 
the  case  of  injury  to  smaller  vessels  or  when  the  indications  point  to 


278 


GUNSHOT   WOUNDS 


cessation  of  hemorrhage,  active  interference  should  be  withheld.  Such 
cases  generallj^  go  on  to  speedy  recovery  by  keeping  the  parts  at  rest. 
If  the  bleeding  persists  as  shown  by  increased  tension,  the  t\imor  should 
be  laid  open,  the  clots  turned  out  and  the  artery  tied  above  and  below 
the  seat  of  injury.  When  this  cannot  be  done  proximal  ligature  to  the 
bleeding  vessels  should  be  practised,  but  in  all  such  cases  the  incision 
in  the  tumor  should  still  be  practised  and  the  cavity  cleansed  of  clots 
to  relieve  pressure,  otherwise  gangrene  may  supervene  from  interfer- 
ence with  the  circulation  below.     The  value  of  the  foregoing  methods 


Fig.  124. — Traumatic  aneurysm  radial 
artery  from,  gun-shot  wound  by  reduced 
caliber  rifle  bullet  in  the  Russo-Japanese 
War.  Treated  by  ligation  and  dissection 
of  sac.  discharged  cured.  Base  Hospital, 
Heroshima,  Dr.  Tanaka,  I.  J.  Army,  Chief 
Surgeon. 


Fig.  125. — Traumatic  aneurysm  of  right 
brachial  artery  from  gun-shot  wound  by  re- 
duced caliber  bullet  in  Russo-Japanese  War. 
Treated  by  ligation  and  dissection  of  sac.  Dis- 
charged cured.  Base  Hospital,  Heroshima,  Dr. 
Tanaka,  I.  J.  Army,  Chief  Surgeon. 


of  treatment  was  well  exhibited  in  the  Anglo-Boer  War.  "Of  forty- 
five  cases  reported  in  detail,  direct  hgature  was  done  in  twenty-seven, 

with  no  death In  ten  of  these  cases  the  vein 

had  also  to  be  tied.  Proximal  ligature  was  done  in  sixteen  cases,  with 
removal  of  the  clot  by  a  separate  incision  in  two  of  the  cases.  None 
of  these  cases  died,  and  in  only  one  gangrene  occured,  after  Hgature  of 
the  femoral  artery"  (Spencer). 


INJURY    TO   BLOOD-VESSELS    AND    NATURE    OF    THE    LESIONS 


279 


Direct  incision  and  ligature  of  the  vessel  at  the  point  of  injury 
was  practised  very  successfully  also  by  the  surgeons  in  the  Manchurian 
campaign  who  generally  deferred  operation,  whenever  possible,  until 
after  healing  of  the  external  wound  to  avoid  the  complications  which 
might  arise  from  infection.  The  latter  was  a  frequent  attendant  in 
vessel  wounds  by  shrapnel  balls,  and  but  seldom  noted  in  wounds  by 
jacketed  rifle  projectiles. 

Circumscribed  traumatic  aneurysms  are  the  result  of  small  openings 
made  in  vessels  at  the  seat  of  a  previous  injury.  The  vessels  are  gen- 
erally surrounded  by  dense  tissues  like  the  popliteal  and  the  tumor  is  of 


Fig.  126. — Traumatic  aneurysm  of  brachial  artery  from  reduced  caliber  rifle  bullet,  in  the 
Russo-Japanese  War,  treated  by  ligation  and  dissection  of  sac.  Discharged  cured.  Base  Hospital 
Heroshima,  Dr.  Tanaka,  I.  J.  Army,  Chief  Surgeon. 

small  size,  seldom  larger  than  a  hen's  egg  and  very  firm.  They  are  of 
a  less  serious  nature  than  the  diffuse  variet}^  of  aneurysm  just  described. 
They  have  the  expansile  pulsation  and  bruit  of  spontaneous  aneurysms. 
The  treatment  is  rest,  under  which  the  majority  show  a  tendency  to 
contract  and  they  occasionally  disappear.  The  tendency,  however, 
is  toward  gradual  enlargement,  and  to  rupture  finally.  The  operative 
treatment  is  usually  practised  sooner  or  later,  and  this  consists  in 
direct  ligation  above  and  below  the  seat  of  injury  and  dissection  of 
the  sac.     If  this  method  is  impracticable,  ligation  just  above  the  seat 


280  GUNSHOT   WOUNDS 

of  injury,  Anel's  operation,  or  Hunter's  operation  should  be  prac- 
tised. Stevenson  states  that  the  majority  of  cases  in  the  Boer  War 
occurred  in  injuries  to  the  pophteal  artery  and  that  the  favorite 
operation  was  to  place  a  ligature  at  the  edge  of  the  adductor  magnus 
because  it  was  less  likely  to  cause  gangrene  than  Hgature  of  the  femoral 
higher  up.  Here  we  have  three  (3)  illustrations  of  traumatic  aneu- 
rysms from  the  Manchurian  campaign  loaned  by  Dr.  Louis  Livingston 
Seaman.     (Figs.  124,  125,  126.) 

Arterio -venous  Aneurysms. — Comminution  between  an  artery  and 
vein  as  a  result  of  trauma  is  known  under  the  designation  of  arterio- 
venous aneurysm.  The  communication  is  effected  in  two  ways  (1) 
aneurysmal  varix — in  which  the  communication  is  direct,  the  artery 
and  vein  being  in  contact;  (2)  varicose  aneurysm — when  a  portion  or 
complete  sac  exists  between  the  two  vessels  through  which  blood  flows 
from  one  to  the  other.  These  communications  are  more  or  less  charac- 
teristic of  gunshot  wounds.  They  are  seldom  met  with  as  a 
result  of  the  traumata  usually  encountered  in  civil  practice,  except  as 
the  result  of  stab  or  punctured  wounds.  They  were  also  noted  in  the 
days  of  the  old-time  operation  of  venesection  at  the  bend  of  the  elbow. 
In  military  practice  they  have  become  more  frequent  as  a  result  of 
reduction  in  the  caliber  of  the  military  rifie,  and  military  surgeons 
report  an  increasing  number  of  instances  among  the  wounded  in  recent 
campaigns.  The  .30-caliber  jacketed  bullet  may  pass  the  line  of  an 
artery  and  vein  lying  adjacent  to  one  another,  notching  both,  or  it 
may  pass  between  the  two  vessels,  notching  their  contiguous  surfaces. 
The  resulting  injury  later  develops  into  an  aneurysmal  varix  or  a 
varicose  aneurysm. 

(1)  Aneurysmal  varix  is  less  comomn  than  varicose  aneurysm,  but 
it  is  more  frequently  met  with  in  those  vessels  which  lie  adjacent  or 
closely  opposed  and  firmly  held  together  like  the  popliteal  vessels  or 
the  femoral  vessels  in  Hunter's  canal.  An  aneurysmal  varix  is  very 
apt  to  occur  also  as  a  result  of  pressure  surgically  applied  to  stay  the 
flow  of  blood.  In  either  case  the  amount  of  effused  blood  is  hmited, 
it  is  later  absorbed,  and  the  communication  between  the  vessels  remains 
with  no  intervening  sac.  An  aneurysmal  varix  may  also  follow  after 
the  temporary  presence  of  a  sac,  when  the  latter  shows  a  tendency  to 
diminish  gradually,  and  finally  to  disappear  with  no  semblance  of  a 
tumor  remaining,  so  that  the  case  which  was  originally  an  arterio- 
venous aneurysm  is  thereby  converted  into  an  aneurysmal  varix. 

Symptoms. — Three  or  four  days  after  the  receipt  of  the  injury  and 


INJURY    TO   BLOOD-VESSELS    AND    NATURE    OF    THE    LESIONS         281 

often  longer,  a  thrill  and  murmur  which  are  constantly  present  make 
their  appearance.  The  thrill  is  more  distinct,  with  slight  palpitation; 
it  extends  over  a  considerable  area  and  when  the  vein  is  exposed,  dur- 
ing an  operation,  the  pulsations  of  the  artery  convey  visible  vibrations 
to  its  walls.  Auscultation  reveals  a  murmur  which  is  loud  and  said 
to  be  audible  at  a  short  distance.  If  the  varix  is  in  the  neck,  the  mur- 
mur is  distinctly  annoying  to  the  patient  at  night  when  he  lies  on  the 
injured  side.  The  tendency  is  toward  dilatation  of  the  artery  immedi- 
ately above  the  point  of  communication  with  the  vein. 

The  prognosis  in  aneurysmal  varix  is  generally  favorable.  There 
is  a  frequent  tendency  to  rapid  pulse  from  100  to  140  per  minute  which 
can  be  lessened  by  a  quiet  mode  of  living.  The  dilated  condition  of 
the  arteries  above  the  communication  with  the  vein  which  develops 
in  the  course  of  years  was  well  shown  in  the  case  of  Captain  Theodore 
Mosher  of  the  22nd  U.  S.  Infantry,  who  was  shot  by  a  Mauser  bullet 
at  Santiago,  July  1,  1898.  The  bullet  entered  the  left  thigh  in  the 
middle  of  Scarpa's  triangle  and  emerged  at  the  level  of  and  1  inch  pos- 
terior to  the  great  trochanter  of  the  corresponding  side.  External 
hemorrhage  was  severe  at  first  and  the  patient  lost  consciousness. 
Wounds  healed  by  primary  intention  in  two  weeks.  When  examined 
for  the  second  time  by  Doctor  Senn  on  or  about  July  15  ,the  patient 
was  anemic.  There  was  a  pulsating  swelling  in  Scarpa's  space  directly 
under  the  wound,  the  characteristic  thrill  and  machinery  murmur 
extended  some  distance  above  and  below  the  point  of  communi- 
cation between  the  artery  and  vein.  The  officer  convalesced  very 
slowly.  He  was  retired  from  active  service  and  placed  on  duty  with 
the  District  National  Guard  at  Washington  where  he  resided  till 
the  time  of  his  death  in  1911,  thirteen  years  after  the  receipt  of  the 
injury. 

Doctor  Thomas  N.  McLaughlin  his  attending  physician  states 
that  there  was  marked  disturbance  to  his  circulation  in  later  years. 
The  pulse  at  the  wrist  was  fast  at  times,  slow  at  others  and  nearly 
always  irregular.  The  dilated  arteries  extended  from  the  bifurcation 
of  the  common  iliac  to  the  lower  third  of  the  thigh.  The  disturbed 
circulation  brought  on  portal  congestion  and  enlargement  of  the  liver 
from  passive  congestion,  the  liver  margin  extending  as  low  as  the 
umbilicus.  The  leg  was  edematous  from  pressure.  There  was  pain, 
strong  pulsation,  and  loss  of  sleep  which  brought  on  nervous  strain. 
In  1906  the  dilated  condition  of  the  arteries  was  very  much  increased, 
the  pain  and  incapacity  for  physical  exercise  became  more  marked. 


282  GUNSHOT   WOUNDS 

Cardiac  hypertrophy,  valvular  lesion,  albuminuria  and  anasarca  were 
noted  toward  the  last. 

The  treatment  of  aneurysmal  varix  will  be  included  under  that  of 
varicose  aneurysm  as  the  measures  of  relief  are  quite  similar  for  both 
conditions. 

Varicose  Aneurysm. — As  stated  already  this  is  the  more  frequent 
of  the  two  forms  of  arterio-venous  communications.  The  forma- 
tion of  a  sac  between  the  two  apertures  in  the  injured  vessels  is  favored 
by  the  anatomical  relations  of  the  vessels,  and  the  amount  of  blood 
effused.  The  formation  of  a  sac  more  often  occurs  between  vessels 
that  lie  in  a  bed  of  loose  areolar  tissue  as  in  Scarpa's  triangle  or  the 
subclavian  vessels.  The  separated  condition  of  the  vessels  favors  a 
greater  amount  of  extravasation  of  blood.  The  latter  becomes  circum- 
scribed, and  forms  a  tumor  which  later  becom.es  the  sac  of  a  varicose 
aneurysm.  It  is  likely  that  more  or  less  extravasation  is  present  in 
all  arterio-venous  communications.  The  tendency  is  for  the  smaller 
amounts  of  effused  blood  to  become  absorbed  before  a  sac  is  formed, 
while  larger  extravasations  being  only  absorbed  in  part  resolve  them- 
selves into  the  formation  of  a  sac.  Some  of  the  operators  in  recent 
wars  claim  that  in  the  majority  of  the  lesions  showing  arterio-venous 
communications  there  is  evidence  of  a  well-formed  sac  or  the  remains 
of  a  pre-existing  sac,  showing  that  the  natural  outcome  of  the  simul- 
taneous wounding  of  the  two  vessels  is  toward  the  formation  of  vari- 
cose aneurysm  in  the  early  history  of  the  majority  of  the  cases. 

Symptoms. — The  pulsation,  thrill  and  bruit  noted  as  symptoms 
of  aneurysmal  varix  are  present  in  varicose  aneurysm.  In  many 
cases  the  thrill  is  present  only  after  the  disappearance  of  the  primary 
swelling  which  follows  the  injury.  Makins  states  that  in  some  cases 
of  arterio-venous  aneurysms  observed  iu  South  Africa  in  the  fore- 
arm, calf,  and  popliteal  space  the  thrill  was  discovered  by  accident 
some  weeks  after  the  injury,  after  no  serious  vascular  lesion  had  been 
suspected. 

The  murmur  common  to  all  these  injuries  is  often  referred  to  under 
the  name  of  "machinery  murmur,"  it  is  widely  distributed,  but  the 
distinguishing  feature  between  varicose  aneurysm  and  aneurysmal 
varix  is  the  presence  of  a  tumor,  showing  expansile  pulsation.  The 
latter  is  often  absent  in  the  early  hisotry  on  account  of  blocking  of 
the  artery,  and  also  in  large  tumors  before  they  have  become  circum- 
scribed. In  this  stage  the  blood  is  diffused  about  the  tissues,  there  is 
no  definite  cavity  and  the  conditions  are  not  favorable  to  the  transmis- 


INJURY   TO   BLOOD-VESSELS    AND    NATURE    OF   THE    LESIONS        283 

sion  of  the  wave  as  they  become  later  mth  the  presence  of  clefinite 
walls. 

The  prognosis  is  far  less  favorable  than  that  of  aneurysmal  varix. 
The  dangers  which  beset  the  patient  are  the  same  as  those  of  spontan- 
eous aneurysm.  Once  a  tumor  has  formed  the  usual  tendency  is  for  it 
to  enlarge  just  as  it  does  in  aneurysm  from  other  causes. 

Treatment. — For  both  aneurysmal  varix  and  varicose  aneurysm  the 
first  indication  is  rest  in  bed,  which  should  be  prolonged  in  accordance 
with  the  progress  noted.  In  cases  of  varicose  aneurysm  rest  in  bed 
as  stated  may  result  in  converting  the  case  into  one  of  aneurysmal  varix, 
a  condition  far  less  serious.  If  the  vessels  implicated  are  in  a  limb,  a 
splint  of  plaster  of  Paris,  in  addition  to  rest,  will  insure  absolute  quiet. 
As  to  the  advisability  for  operative  treatment  this  depends  upon  the 
vessels  affected  and  the  amount  of  disturbance  present.  The  vessels 
of  the  upper  extremity  offer  the  best  results  for  operative  treatment, 
and  this  is  especially  true  of  the  brachial  and  its  accompanying  vessels. 
The  vessels  of  the  forearm  frequently  show  no  serious  symptoms  so 
that  operation  there  is  not  always  necessary.  The  femoral  and  pop- 
liteal vessels  should  not  be  operated  upon  except  in  cases  of  necessity. 
In  the  leg  the  tibial  vessels  may  be  operated  upon  Avith  safety. 

The  most  effective  operation  for  both  forms  of  arterio-venous  com- 
munications is  ligation  of  the  artery  above  and  below  and  as  near  as 
possible  to  the  point  of  communication  wdthout  interference  to  the 
vein.  This  operation  is  nearly  always  practicable  in  the  limbs  and  it 
is  especially  adapted  to  the  relief  of  aneurysmal  varix.  Proximal  liga- 
ture should  be  avoided  when  possible  as  it  is  apt  to  be  attended  with 
gangrene,  although  Stevenson  states  that  in  several  operations  where 
proximal  ligature  was  tried  in  South  Africa,  gangrene  did  not  appear. 

Varicose  aneurysms  usually  show  a  tendency  to  enlarge  and  eventu- 
ally to  rupture,  in  which  case  the  indications  are  the  same  as  for 
traumatic  aneurysms  of  the  diffused  kind.  Ligation  above  and  below 
the  point  of  communication  in  varicose  aneurysms  is  the  ideal  opera- 
tion in  small  tumors.  The  hgature  should  be  applied  in  sound  tissue 
as  close  as  possible  to  the  sac. 

In  arterio-venous  communications  involving  the  large  vessels  of 
the  neck  operation  should  be  avoided  until  rendered  necessary  by  the 
increasing  effects  of  pressure  from  dilated  vessels  or  extension  of  the 
sac,  in  the  case  of  a  varicose  aneurysm.  Here  the  most  suitable  and 
most  generally  the  only  operation  available  is  ligature  of  the  main 
trunk  on  the  proximal  side  of  the  sac.     The  sac  consolidates  and  disap- 


284  GUNSHOT   WOUNDS 

pears  in  the  course  of  a  few  months.     The  thrill  and  slight  pulsations 
remain  in  some  cases  with  no  tendency  to  increase. 

GUNSHOT  INJURIES  TO  PERIPHERAL  NERVE  TRUNKS 

Injuries  to  nerves  by  gunshot  have  assumed  additional  interest 
with  the  use  of  the  improved  armament  in  modern  wars.  Except  in 
the  case  of  injuries  implicating  the  great  nerve  centers  wounds  of  this 
class  have  been  attended  by  a  very  small  percentage  of  mortality. 
Gunshot  injuries  to  nerves  were  formerly  recognized  as  a  group  which 
often  resulted  in  complete  and  permanent  disability,  accompanied  by 
much  suffering  and  only  occasionally  amenable  to  treatment.  Doubt- 
less much  of  the  protracted  suffering  and  hopeless  condition  arose  from 
pressure  symptoms  as  a  result  of  lodged  missiles,  callus,  and  cicatricial 
bands  in  old  infected  wounds.  Hopeless  paralyses  came  from  absence 
of  our  present  knowledge  of  nerve  suture. 

The  character  of  the  wounds  from  the  soft,  larger-caliber  lead  bul- 
lets also  added  to  the  frequency  of  traumatism  like  severe  contusion, 
and  partial  or  complete  division  of  nerve  trunks.  The  same  lesions  also 
occur  from  the  mihtary  rifle  projectiles  of  the  present  day,  the  contu- 
sions are  neither  so  extensive  nor  so  frequent,  but  instead  a  large  class 
of  disabling  wounds  as  a  result  of  vibratory  concussion  on  nerve  trunks 
has  figured  prominently  among  nerve  injuries  in  recent  wars. 

Concussion  of  individual  nerves  is  almost  entirely  identified  with 
the  effects  of  the  high-power  rifle  bullet  and  the  degree  of  concussion 
noted  is  closely  related  to  the  velocity  of  the  bullet  at  the  time  of 
impact.  As  pointed  out  in  transverse  lesions  of  the  spinal  cord  from 
the  same  cause  it  is  not  necessary  that  the  projectile  should  come  in 
direct  contact  with  the  nerve  substance.  Temporary  and  complete 
loss  of  function  of  an  adjoining  nerve  is  common  enough  now,  after 
fracture  of  the  shaft  of  a  long  bone.  The  amount  of  concussion  which 
the  nerve  trunk  suffers,  and  the  disabling  effects  thereform,  are  pro- 
portional to  the  resistance  of  the  bone  hit  and  the  velocity  of  the  bullet. 
Thus  the  effects  are  more  frequently  noted  after  a  high-velocity  bullet 
encounters  the  compact  substance  of  the  shaft  than  we  find  in  cases 
where  the  bullet  traverses  the  cancellous  end  of  a  bone.  But  concus- 
sion of  a  nerve  from  the  vibratory  impulse  caused  by  the  bullet  travers- 
ing soft  tissues  alone  is  also  met  with,  showing  that  the  transmitted 
energy  from  the  bullet  alone  is  sufficient  to  produce  the  lesion  that  we 
call  nerve  concussion.  Such  a  lesion  may  be  accompanied  by  all  the 
symptoms  of  complete  section,  which  may  persist  for  many  months. 


GUNSHOT   INJURIES   TO    PERIPHERAL    NERVE    TRUNKS  285 

The  nature  of  the  anatomical  lesion  is  not  demonstrable  micro- 
scopically nor  macroscopically.  All  we  know  is  that  a  section  of  the 
affected  nerve  is  for  the  time  being  completely  destroyed  as  a  conductor 
of  impulses,  the  connective  tissue  remaining  intact.  In  discussing 
gunshot  wounds  of  the  neck  we  cited  cases  of  nerve  lesion  from  concus- 
sion observed  at  Santiago,  to  which  the  reader  is  referred. 

We  are  specially  indebted  to  Mr.  Makins  and  Col.  Sylvester^ 
for  the  painstaking  way  in  which  they  have  described  their  rich  expe- 
rience in  nerve  lesions  during  the  Anglo-Boer  War.  Cases  which  were 
once  more  or  less  obscure  are  now  readily  understood  by  the  explana- 
tion of  the  transmission  of  vibratory  concussion  or  the  dispersion  of 
the  bullet's  energy.  Cases  of  this  kind  were  duly  appreciated  by  the 
older  writers  and  especially  by  Acting  Assistant  Surgeons  Mitchell, 
Morehouse  and  Keen,  U.  S.  A.,  and  quoted  by  Otis.  In  writing  of 
such  injuries  to  the  brachial  plexus,  for  instance,  they  attributed  the 
paralysis  to  "brief  compression  of  the  (nerve)  trunks  during  the  move- 
ment of  the  missile  or  to  agitation  of  the  nerves  through  the  tearing  of 
tissues  more  or  less  remote."  In  other  parts  of  their  work  they  often 
use  the  word  "commotion"  to  convey  the  meaning  of  vibration  as  a  re- 
sult of  the  bullet's  energy.  Such  cases  were  not  then  so  frequent  as 
they  are  now  because  of  the  lower  velocity  and  energy  of  the  bullets 
then  in  use. 

Symptoms  of  Concussion. — Among  the  most  common  symptoms 
will  be  found  partial  or  complete  loss  of  function  which  includes  loss 
of  sensation  only  or  loss  of  both  sensation  and  motion.  The  symp- 
toms are  temporary  in  character,  lasting  seldom  more  than  a  week 
or  ten  days.  In  slight  cases  there  is  complete  or  partial  anesthesia  of 
3,  transient  character  in  the  skin  distribution  of  the  nerve  accompanied 
by  tingling  sensations.  In  the  more  severe  cases  the  loss  of  motion 
and  sensation  is  absolute  as  one  always  finds  in  the  complete  division 
of  a  nerve,  with  subsequent  wasting  of  muscles  and  the  usual  trophic 
changes  in  the  skin,  nails,  etc.  Though  seemingly  hopeless,  these 
cases,  whether  complete  nerve  degeneration  has  been  established  or 
not,  undergo  the  process  of  regeneration,  during  which  sensation  is 
the  first  to  return,  to  be  followed  by  motion  later  on. 

Contusion. — This  traumatism  is  produced  by  slight  contact  of  the 
bullet,  secondary  missiles  or  spiculse  of  bone  with  the  nerve  proper, 
although  the  presence  of  any  anatomical  lesion  is  not  always  very 

^  Gunshot  Injuries  of  Peripheral  Nerves  in  Reports  of  Surgical  cases  in  South 
African  War  by  Lt.-Col.  Sylvester,  R.A.M.C.     (Stevenson.) 


286  GUNSHOT   WOUNDS 

definite.  The  symptoms  of  contusion  are  often  attended  with  slight 
hemorrhage  among  the  nerve  fibers  the  presence  of  which  is  suggested 
by  signs  of  irritation,  hke  pain  and  hyperesthesia.  Differentiation 
between  concussion  and  contusion  is  often  difficult.  Generally,  con- 
tusion is  a  much  more  serious  condition  than  concussion. 

Symptoms. — The  symptoms  of  contusion,  in  so  far  as  motion  and 
sensation  are  concerned,  resemble  those  of  division  of  a  nerve,  but  they 
are  not  so  complete.  There  is  still  reaction  of  the  muscles  to  the 
stimulus  of  electricity  but  it  is  cUminished.  Some  of  the  muscles  to 
which  the  affected  nerve  is  chstributed  may  exhibit  complete  paralysis, 
while  others  still  respond  to  the  faradic  current.  The  loss  of  sensation 
is  also  irregular,  occurring  in  patches.  Trophic  changes  such  as  red- 
ness of  the  skin,  eczema,  club  nails,  pain,  stiffness,  poHshed  skin,  loss 
of  hair,  hyperesthesia  and  burning  sensations  may  appear.  The 
muscles  may  atrophy  and  become  flaccid. 

Recovery  is  always  to  be  expected.  This  may  be  deferred  for 
months,  and  then  in  cases  of  more  or  less  complete  paralysis  recovery 
of  wasted  muscles  will  take  place  suddenly.  Sensation,  as  noted  in 
cases  of  concussion,  usually  precedes  the  appearance  of  motion,  and 
its  return  is  regarded  as  a  valuable  diagnostic  and  prognostic  sign. 

Partial  Division. — This  is  one  of  the  common  traumatisms  from 
gunshot.  According  to  the  reporters  from  the  Manchurian  campaign 
the  large  majority  of  such  cases  were  noted  as  a  result  of  injury  from 
the  jacketed  bullets.  Fischer  states  that  Hashimoto  found  77  per  cent. 
and  Schaefer  90.6  per  cent,  of  their  cases  as  a  result  of  wounds  by 
these  projectiles.  In  most  of  the  cases  the  larger  nerves  were  slit  by 
the  bullets  but  bullets  were  also  known  to  perforate  nerves  smaller 
than  their  own  caliber.  Slits  were  commonly  seen  in  nerves  of  3  mm. 
in  diameter  and  over.     Notching  was  more  common  than  perforations. 

Symptoms. — In  partial  lesions  response  to  electrical  stimulation 
is  incomplete  save  in  those  cases  attended  with  concussion,  but  the 
transient  nature  of  the  latter  is  soon  revealed  by  return  of  sensation 
to  electrical  stimulation.  The  loss  of  sensation  and  motion  is  not  pro- 
longed in  the  distribution  of  those  fibers  which  escaped  division." 

Complete  Division. — This  traumatism  is  commonly  observed  in 
the  smaller  nerves.  It  cannot  well  occur  in  the  larger  nerves  like  the 
great  sciatic  by  the  small  jacketed  bullet  except  as  a  result  of  injury 
from  a  deformed  bullet  and  from  shots  when  the  bullet  is  travelling  at 
a  tangent  to  its  line  of  flight.  In  such  cases  the  largest  nerves  suffer 
complete  section.     The  extent  of  nerve  involvement  depends  upon  the 


GUNSHOT   INJURIES   TO    PERIPHERAL   NERVE    TRUNKS  287 

angle  of  impact.  When  the  bullet  traverses  the  nerve  at  right  angles 
the  loss  of  nerve  substance  corresponds  to  the  caliber  of  the  projectile 
and  when  the  course  of  the  nerve  is  hit  obliquely  an  inch  or  more  of 
nerve  tissue  may  be  involved. 

Symptoms. — Complete  cUvision  of  a  nerve  is  followed  by  loss  of 
sensation  and  motion  in  its  distribution.  In  a  few  days  the  muscles 
fail  to  react  to  the  faradic  current  and  this  is  followed  soon  thereafter 
by  the  customary  signs  pertaining  to  reaction  of  degeneration  and  the 
well-known  trophic  changes  in  the  skin,  hair,  nails,  etc. 

A  positive  diagnosis  is  to  be  made  if  there  is  total  loss  of  response 
to  electric  stimulus  by  the  nerve  trunk,  or  the  diagnosis  is  equally 
certain  in  the  case  of  nerves  superficially  placed  if  the  bulbous  end  can 
be  identified  by  touch. 

Treatment. — The  treatment  of  injury  to  peripheral  nerves  is  expec- 
tant and  operative. 

In  the  expectant  treatment  we  employ  warmth  and  complete  rest 
by  means  of  a  splint  for  at  least  one  month.  At  the  end  of  this  time 
if  pain  and  tenderness  have  sufficienth'  passed  away  the  use  of  the 
galvanic  current,  gentle  massage  and  passive  movement  of  joints  should 
be  commenced.  Morphia  is  to  be  used  to  subdue  pain  only  when 
absolutely  necessary.  Every  precaution  to  prevent  infection  of  the 
wound  should  be  practised  from  the  beginning  as  suppuration  pro- 
longs recovery  and  adds  to  complications  like  neuritis,  and  pain  from 
subsequent  contraction  in  cicatricial  tissue. 

The  treatment  by  operation  may  be  divided  into  (1)  immediate, 
(2)  intermediate  and  (3)  operation  for  secondary  involvement. 

(1)  Immediate  operation  is  practised  when  for  other  reasons  dur- 
ing an  operation  or  exploration  a  divided  nerve  trunk  comes  into  view 
in  which  case  it  should  be  sutured  before  the  wound  is  finally  closed. 

(2)  Intermediate  operation  should  not  be  undertaken  before  the 
end  of  two  months  or  more  because  the  necessity  for  operation  is  often 
not  revealed  until  this  lapse  of  time.  Operation  is  imperative  at 
about  this  time  when  the  nerve  trunk  has  been  completely  divided, 
but  the  establishment  of  the  presence  of  such  an  injury  can  only  be 
made  by  the  symptoms  that  develop,  and  these,  as  we  have  already 
pointed  out,  are  so  entirely  simulated  by  the  symptoms  of  concussion, 
contusion,  or  a  combination  of  both,  that  it  is  always  in  order  to  wait 
a  reasonable  time  for  the  signs  of  recovery  that  are  sure  to  appear 
after  these  minor  lesions.  The  recovery  that  follows  the  latter  takes 
place  without  operation.     The  process  of  repair  in  concussion  or  con- 


288  GUNSHOT   WOUNDS 

tusion  is  often  prolonged  since  the  nerve  undergoes  degeneration  and 
subsequent  regeneration  of  the  distal  end  before  signs  of  returning 
function  are  noted.  Experience  teaches  that  nothing  is  lost  by  delay 
in  operating  for  division  of  a  nerve  trunk.  Premature  operations  have 
often  been  undertaken  only  to  find  that  the  nerve  trunk  was  intact 
and  apparently  normal  such  as  we  always  expect  to  find  in  concussion 
with  or  without  contusion. 

In  the  case  of  a  divided  nerve  operation  should  only  be  undertaken 
after  the  lapse  of  the  time  mentioned  and  after  all  reaction  to  faradiza- 
tion has  disappeared,  when  the  muscles  continue  to  waste  and  the 
trophic  changes  mentioned  are  progressing. 

When  the  opportunity  arises  to  suture  a  nerve  at  the  time  of  the 
primary  dressing,  this  should  be  clone  under  strict  asepsis.  Suturing 
is  best  done  at  this  time  with  a  small  round  sewing  needle,  threaded 
with  fine  chromicized  catgut  or  silk  suture,  through  the  sheath  of  the 
nerve,  employing  the  mattress  stitch  or  Lembert  suture.  The  ends 
of  the  nerve  should  be  brought  snug  together  to  promote  restoration 
of  function.  When  the  whole  of  the  nerve  trunk  cannot  be  sewed 
together  the  parts  or  filaments  that  can  be  identified  should  be  care- 
fully sutured.  When  loss  of  substance  has  occurred  stretching  of  the 
divided  ends  to  secure  approximation  is  permissible.  When  the 
loss  has-been  considerable  grafting  the  distal  end  to  an  adjoining  nerve 
may  be  practised.  The  limb  should  be  fixed  with  a  plaster-of-Paris 
splint  for  several  weeks  in  a  position  to  avoid  traction  on  the  ends  of 
the  divided  nerve.  Later  prolonged  treatment  by  massage,  elec- 
tricity and  gj^mnastics  should  be  employed.  The  bulbous  ends  may 
be  split  and  turned  toward  each  other  to  fill  the  gap,  or  in  place  of  this 
method  the  usual  forms  of  splicing  known  to  surgeons  may  be  employed. 

(3)  Operations  for  Secondary  Involvement. — Operation  is  often 
necessary  when  a  nerve  becomes  painful  and  its  function  is  otherwise 
interfered  with  by  pressure  in  scar  tissue  or  in  callus.  In  such  a  case 
the  nerve  should  be  exposed,  freed  from  all  adhesions,  and  stretched. 
It  sometimes  becomes  necessary  to  stretch  nerves  afflicted  with  neu- 
ralgia that  were  only  grazed  primarily  by  bullets,  with  no  apparent 
lesion  other  than  possible  traction  from  adjoining  cicatricial  tissue. 


CHAPTER  XI 

Gunshot  Wounds  of  Joints 

The  gravity  of  wounds  of  the  larger  joints  until  recent  years  ranked 
next  to  those  of  the  large  body  cavities.  The  present-day  beneficent 
results  in  joint  wounds  by  gunshot  are  far  more  striking  to  the  military 
surgeon  than  they  are  to  the  civilian  practitioner.  The  latter  has 
noted  marked  improvement  as  a  result  of  the  introduction  of  anti- 
sepsis, while  the  former  has  in  addition  to  antisepsis  noted  marked 
beneficence  from  the  use  of  the  reduced-caliber  projectiles  as  well. 

The  happ3^  results  which  arise  from  the  use  of  the  jacketed  bullets 
were  foretold  by  all  the  experimenters  before  the  use  of  these  bullets 
was  undertaken  in  warfare.  Those  who  w^ere  concerned  in  testing 
the  reduced-caliber  rifles  in  the  beginning  observed  the  striking  change 
in  the  character  of  joint  wounds  especially.  Since  the  destructive 
effects  in  tissues,  as  often  stated  already,  are  proportional  to  the  velocity 
of  the  bullet,  its  sectional  area,  and  the  resistance  which  it  encounters 
on  impact,  we  found  that  the  spongy  nature  of  the  epiphyseal  ends 
of  bones  offer  a  minimum  amount  of  resistance,  and  that  the  epiphyses 
except  in  the  very  proximal  ranges,  were  perforated  without  fissure, 
in  the  same  manner  that  soft  tissues  generally  are  perforated.  In 
other  words  the  tendency  of  the  armored  bullet,  in  passing  through 
the  joint  ends  of  bones,  is  to  make  a  clean-cut  perforation  without 
fracture  and  the  chances  of  complete  recovery,  with  the  use  of  a  simple 
dressing  and  subsequent  immobilization,  is  assured  in  nearly  all  cases. 

The  lesion  inflicted  in  the  joint  ends  of  bone  by  the  large-caliber 
lead  bullet  in  former  w^ars  favored  the  development  of  sepsis  to  a 
marked  degree.  The  soft  lead  bullet  was  prone  to  lodge  and  it  gen- 
erally deformed  on  impact  against  the  bony  structures,  thereby 
increasing  its  sectional  area.  The  amount  of  laceration  of  the  soft 
parts  attendant  upon  the  displacement  of  bone  fragments  caused  ex- 
tensive hematomata  about  the  cellular  tissue,  the  synovial  membrane, 
and  joint  attachments.  The  bone  itself  was  fragmented  and  fissured 
so  that  the  lesion  in  itself  particularly  augmented  the  development 
and  spread  of  the  infection  that  was  invariably  carried  with  the  ball, 

289 


290 


GUNSHOT   WOUNDS 


as  well  as  that  which  was  forced  into  the  wound  with  particles  of 
clothing  and  the  integument.  Such  cases  were  invariably  septic, 
and  the  niortality  was  correspondingly  great. 

The  changes  that  have  been  wrought  in  recent  years  from  the  use 
of  antisepsis  and  the  new  armament  are  at  once  shown  in  the  follow- 
ing tabular  statements.^ 

PERCENTAGE  MORTALITY  FROM  WOUNDS  OF  THE  JOINTS  IN  FIVE 

WARS 


Joint 


American 
Civil 
War 

Franco- 
Prussian 

I 
1 

Japan- 
China 
(Haga) 

Spanish- 
American 

Anglo 
Boer 
War 

84.7 

1 
1 

71.8 

100.0 

1 
33.0 

28.5 

53.7 

48.9 

25.0 

5.5 

4.2 

26.9 

24.0       1 

0.0 

0.0 

0.0 

31.1 

35.5 

0.0 

0.0 

3.7 

9.4 

21.2 

0.0 

0.0 

2.0 

12.9 

12.6 

0.0 

0.0 

0.0 

Hip 

Knee.  . .  . 
Ankle . . . 
Shoulder 
Elbow. .  . 
Wrist... 


CASES  AND  DEATHS  IN  EACH  CLASS  OF  JOINT  WOUNDS  IN  THREE 

RECENT  WARS 


Joint 

Japan-China  War 
(Haga) 

Spanish-American 

War  and  Philippine 

Insurrection 

Anglo-Boer  War 

Number 

Deaths 

Number 

Deaths 

Number 

Deaths 

Hip 

Knee 

Ankle 

Shoulder 

Elbow 

Wrist 

1 
16 

4 

4 
16 

6 

1 

4 
0 
0 
0 
0 

3 

77 
26 

9 
44 

6 

1 
2 
2 
1 
1 
0 

7 
95 
40 
27 
49 
10 

2 
4 
0 
1 
1 
0 

Total 

Mortality,     per 
cent. 

47 

5 
10.6 

165 

6 
3.6 

228 

8 
3.4 

1  W.  C.  Borden,  Lt.-Col.  U.  S.  A.,  in  Vol.  II,  Bryant  and  Buck  American 
Practice  of  Surgery. 


GUNSHOT   WOUNDS    OF   JOINTS  291 

In  the  Manchurian  campaign  Follenfant,  quoting  from  the  Khar- 
bine  statistics  of  1905,  found  1382  gunshot  injuries  of  joints  with  but 
seven  deaths  and  sevent^'^-two  resections.  It  is  safe  to  state  that  the 
latter  were  not  from  fractures  caused  by  the  reduced-caliber  bullet 
but  more  likely  shots  from  shell  fragments  or  shrapnel.  Projectiles 
from  the  latter  sources  still  cause  extensive  fracture  in  the  epiphyseal 
ends  of  bones,  with  tendency  to  suppuration.  Surgical  interference 
in  the  way  of  partial  excision  with  drainage  is  to  be  practised  in  the 
large  majority  of  such  cases,  in  order  to  preserve  life  and  limb. 

Vibration  Synovitis. — Mr.  Makins  has  called  the  attention  of  the 
profession  to  synovitis  as  a  result  of  the  vibratory  force  which  shocks 
a  joint  by  the  dispersion  of  the  energj^  of  the  high-power  modern  rifle 
bullet.  In  such  cases  he  found  a  "considerable  amount  of  synovial 
effusion  into  joints  of  limbs  in  which  the  articulation  itself  was  prim- 
arily untouched."  He  found  these  effusions  also  in  cases  where  the 
soft  parts  alone  had  been  traversed,  in  tissues  near  the  knee-joint 
especially,  and  he  attributes  them  to  the  shock  of  impact  conveyed 
to  the  entire  limb;  but  he  found  these  effusions  most  generally  after 
fracture  of  the  diaphysis  and  notably  so  in  the  hip,  knee-  and  ankle- 
joints,  and  not  so  often  in  the  joints  of  the  upper  extremity.  The 
theory  of  vibratory  synovitis  is  most  tenable  to  us  and  one  that  will  no 
doubt  attract  the  attention  of  military  surgeons  very  much  hereafter. 

Gunshot  wounds  of  joints  are  usually  divided  as  follows: 

1.  Lesion  of  joint  without  injury  to  osseous  structures. 

2.  Wounds  of  joint  accompanied  by  lodged  missile. 

3.  Lesion  of  joint  marked  by  grooving  of  the  articular  ends  of 
bones. 

4.  Perforation  of  articular  ends  across  the  joint. 

5.  Comminution  of  articular  ends  of  bones. 

(1)  Lesion  of  Joint  without  Injury  to  Osseous  Structures. — These 
were  rare  injuries  with  the  use  of  the  old  armament.  The  capsule 
of  the  joint  is  opened  by  the  bullet  without  inflicting  injury  to  the  bones 
entering  into  the  formation  of  the  joint.  This  is  more  apt  to  occur 
in  the  wounds  of  the  knee.  With  the  present-day  military  rifle 
bullet  this  occurrence  is  not  infrequent.  The  ill  effects  are  but  slight, 
due  principally  to  effusion  of  blood  in  the  joint.  There  is  little  danger 
of  infection.     Rest  on  a  splint  is  the  only  treatment  required. 

(2)  Wounds  of  Joints  Accompanied  by  Lodged  Missiles. — This 
form  of  injury  was  present  in  olden  times  with  the  use  of  low  velocities. 
The  U.  S.  Army  Medical  Museum  has  a  rich  collection  of  such  cases 


292 


GUNSHOT   WOUNDS 


from  our  Civil  War.  Because  of  the  superior  velocity  conferred  on 
the  high-power  military  rifle  of  the  present  day,  lodged  rifle  projectiles 
in  joints  are  now  of  rare  occurrence  in  war.  Wounds  of  this  kind  are 
still  common  from  shrapnel  and  fragments  of  shells,  and  from  pistol 
balls  in  civil  practice. 

(3)  Superficial  Grooving  of  the  Bones. — In  these  cases  there  is  a 
superficial  grooving,  and  although  the  joint  is  not  so  directly  implicated, 
these  wounds  prove  by  far  the  most  serious  because  of  the  great  danger 
to  infection  which  is  inherent  in  the  character  of  the  wound.     The 


Fig.  127.  Fig.  128. 

Fig.  127.— Photograph  in  case  of  Corpl.  H.  C.  S.,  Co.  "F,"  122nd  N.  Y.,  shot  March  27,  1865. 
Globular  head  of  femur  is  shattered  by  conoidal  ball  which  remains  lodged.  Head  of  bone  ex- 
cised at  junction  with  neck.  Acetabulum  was  involved.  Died  from  peritonitis  Apr.  8,  1865. 
No.  9821.     A.  M.  M.  collection. 

Fig.  128. — Pvt.  J.  R.  Co.  "C"  69th  N.  Y.  Wounded  March  25,  1865.  Died  of  exhaustion 
Apr.  6,  1865.  Conoidal  ball  entered  anteriorly  and  lies  lodged  in  great  trochanter.  A  fissure 
6  inches  long  extends  down  the  shaft  from  the  point  of  lodgment.     No.   98211,  A.  M.  M.  collection. 

entrance  and  exit  wounds  in  the  skin  are  generally  oval  since  the  bullet 
enters  and  leaves  the  skin  at  a  tangent  to  the  surface.  This  in  itself 
invites  the  development  of  infection.  The  injury  to  the  capsule  is 
often  marked  by  a  superficial  tear  of  some  length  as  seen  in  the  knee 
especially,  with  spicules  of  bone  protruding.  The  synovial  sac  is 
naturally  more  extensively  involved  from  a  long  narrow  track  made 


GUNSHOT   WOUNDS    OF   JOINTS  293 

by  the  ball  than  it  is  when  it  suffers  two  direct  perforating  wounds. 
Movement  of  a  joint  so  injured,  a  common  occurrence  in  war,  adds  to 
the  traumatism  and  to  existing  infection.  Absolute  fixation  of  a 
limb  so  injured  should  be  practised  at  once.  Wounds  in  the  neighbor- 
hood of  joints  should  all  be  treated  as  gutter  wounds  of  the  synovial 
membrane. 


Fig.  129. — Pvt.  M.  J.  52nd  N.  Y.  Photograph  shows  shattering  of  tibia  into  ankle-joint 
by  conoidal  bullet  with  long  fissures  extending  in  shaft.  Shot  at  Chancellorsville,  Mar  3,  1863. 
Amputation  on  fourth  day  after  injury.     No.  1173.     A.  M.   M.  collection. 

4.  Perforation  of  Articular  Ends  Across  the  Joint. — These  are  the 
most  favorable  of  the  joint  perforations  to  treat  and  this  is  especially 
so  with  the  shots  delivered  perpendicular  to  the  joint  surface,  in  which 
case  the  joint  is  traversed  by  the  shortest  route,  inflicting  a  minimum 
amount  of  injury.  (Figures  130  and  131.)  Long  oblique  tracks  through 
the  bones  are  attended  with  more  traumatism  and  greater  liability  to 
infection  as  in  the  case  of  the  long  narrow  groves  seen  in  shots  which 
gutter  the  joint  ends.  The  tendency  to  the  development  of  infection 
in  all  joint  wounds  is  measured  by  the  size  of  the  wounds  of  entrance 
and  exit  in  the  skin  and  the  degree  of  traumatism  in  the  structures 
entering  into  the  formation  of  the  joint.  It  is  obvious  from  this 
statement  that  the  amount  of  infection  is  largely  dependent  upon  the 
sectional  area  of  the  bullet.     Perforations  of  the  articular  ends  of 


294  GUNSHOT    WOUNDS 

bone  by  the  armored  bullets  are  generally  clean  cut  without  Assuring 
or  splintering.  In  cases  where  the  track  of  the  bullet  is  near  the  sur- 
face of  the  bone,  fissuring  into  the  joint  may  occur,  but  these  cases 
simulate  those  described  under  the  Lesions  of  Joints  Marked  by  Groov- 
ing, etc.,  and  they  are  correspondingly  serious. 


Fig.  130. — Radiographs  of  left  knee,  showing  lateral  and  postero-anterior  view  of  left  knee 
in  the  case  of  Pvt.  Ernest  Knowles,  Co.  "D,"  21st  U.  S.  Inf.,  wounded  in  Philippine  Insurrection 
Oct.  28,  1899  by  a  ricochet  .45  cal.  brass-jacketed  Remmington  bullet.  ^  The  ball  entered  e.xternal 
surface  of  thigh  about  its  middle  and  passing  perpendicularly  through  osseous  structures  of  knee- 
joint,  it  lodged  in  the  head  of  tibia  from  which  it  was  removed  by  the  author  in  May  1900.  A  shot 
obliquely  or  transversely  disposed  through  the  joint  by  such  a  large  missile  would  have  caused  much 
destruction  of  bone  with  a  less  happy  result.  Remote  effects:  Some  stiffness  and  pain  in  knee  which 
disappeard  partially  after  the  bullet  was  removed.  The  photograph  of  bullet  appears  in  Fig.  131. 
U.  S.  Soldiers  Home  X-ray  Laboratory.     Dr.  A,   B.  Herrick,  X-rayist. 

(5)  Comminution  or  the  Articular  Ends  of  Bones. — Extensive  trau- 
matism of  joint  structures  is  usually  caused  by  gunshot  from  shell 
fragments,  large  lead  bullets,  shrapnel  balls  and  proximal  shots  at 
contact  or  only  a  few  feet  from  the  muzzle  by  the  high-power  military 
rifles  of  the  present.  (Fig.  132.)  From  the  amount  of  fragmentation 
of  the  osseous  structures,  laceration  of  the  soft  parts  and  the  larger 
skin  wounds,  these  wounds  are  the  most  dangerous  variety  of  joint 
injury,  because  of  the  presence  and  spread  of  infection  which  is  almost 
inevitable  in  war  wounds,  especially  in  active  campaign. 


GUNSHOT   WOUNDS    OF   JOINTS 


295 


Symptoms  ot  Wounds  or  Joints. — The  first  and  almost  invariable 
result  of  gunshot  of  a  joint  is  the  appearance  of  effusion  composed  of 
synovial  fluid  and  blood  which  increases  for  the  first  twenty-four 
hours.  In  the  less  severe  cases,  under  quiet  and  fixation  of  the  limb, 
absorption  will  take  place  in 
from  two  to  four  weeks.  A 
general  rise  of  temperature  will 
usually  appear  during  this  time 
from  absorption  of  fibrin  ferment 
in  the  effused  blood  or,  as  has  re- 
cently been  suggested,  from  the 
presence  of  staphylococcus 
albus.  This  rise  in  tempera- 
ture is  transient  and  slight  and 


Fig.   131.  Fig.  132. 

Fig.  132. — Shows  the  result  of  an  experimental  shot  in  the  cadaver  of  a  man  of  60  years  by  the 
U.  S.  A.  pointed  rifle  bullet  of  .30  cal.  impressed  by  its  maximum  velocity  of  2700  f.s.  Aside  from 
the  shattering  effects  of  high  velocity  the  brittle  condition  of  the  bones  of  the  aged  no  doubt  con- 
tributed to  the  degree  of  traumatism.     Army  Medical  School  X-ray  Laboratory. 

very  unlike   the   fever   and  constitutional  disturbance  which  accom- 
panies acute  septic  arthritis. 

Escape  of  synovial  fluid  from  the  external  wound  occasionally 
occurs,  and  when  it  does  it  is  positive  evidence  that  the  synovial 
sac  has  been  penetrated,  but  cases  of  this  kind  are  confined  to  large 
external  wounds  having  free  communication  with  the  joint.  When 
synovia  is  not  seen,  the  diagnosis  of  joint  injury  is  to  be  made  from 
the  track  of  the  bullet  as  determined  by  the  location  of  the  external 

20 


296  GUNSHOT   WOUNDS 

wounds.  When  doubt  of  joint  implication  exists,  the  surgeon  should 
nevertheless  treat  the  case  as  one  of  joint  injury. 

Joints  are  sometimes  implicated  in  injuries  to  the  shafts  of  the  long 
bones  by  the  high-power  rifles.  Fissures  of  great  length  are  frequently 
seen  in  the  femur  and  humerus  more  often  from  shot  injuries  at  the 
mid  ranges.  The  fissures  may  or  may  not  be  subperiosteal  and  they 
extend  into  the  neighboring  joints  causing  more  or  less  effusion  into 
the  synovial  sac.  These  cases  are  difficult  to  separate  from  the  vibra- 
tion synovitis  of  Mr.  Makins.  In  cases  where  the  wound  becomes 
septic,  however,  the  presence  of  fissures  into  the  joint  becomes  un- 
mistakable because  the  septic  process  invariably  extends  along  the  fis- 
sures into  the  joint. 

Treatment. — This  includes  (1)  amputation,  (2)  excision  and  (3) 
conservative  treatment. 

(1)  Amputation  was  the  rule  of  treament  in  all  wounds  of  large 
joints  with  the  possible  exception  of  the  elbow  in  the  days  of  the  old 
armament.  The  lesion  was  then  more  extensive  and  sepsis  was 
present  in  all  cases.  The  surgeon's  ability  to  control  sepsis  and  the 
favorable  character  of  the  lesions  inflicted  by  the  modern  military 
rifle  has  reduced  amputation  for  joint  wounds  to  a  minimum  in 
the  wars  of  the  present.  Primary  amputation  is  only  done  now  in 
cases  of  great  destruction  of  the  soft  parts  and  interference  with  the 
blood  and  nerve  supply,  such  as  are  common  from  shell  wounds.  The 
surgeon  is  often  tempted  to  save  limbs  when  the  vessels  and  nerves 
alone  have  been  destroyed  and  when  the  injury  to  the  joint  proper 
is  of  secondary  importance.  Our  experience  among  invalided  and 
discharged  soldiers  at  the  U.  S.  Soldiers  Home,  Washington,  has  con- 
vinced us  that  conservatism  can  be  carried  too  far  and  that  when 
the  blood  and  nerve  supply  have  suffered  extensive  destruction  ampu- 
tation is  better  than  conservation  in  the  long  run.  The  atrophied 
and  paralyzed  members  have  to  be  sacrificed  ultimately.  Primary 
amputation  avoids  a  great  deal  of  protracted  suffering,  and  further- 
more the  soldier's  pension,  which  is  liberal  for  the  loss  of  an  arm  or 
leg  in  our  country,  becomes  at  once  available. 

As  far  as  known  no  amputation  resulted  either  in  the  Spanish- 
American  or  Boer  War  for  gunshot  of  a  large  joint  by  the  small  jacketed 
bullet.  An  amount  of  destructive  effect  necessary  to  require  amputa- 
tion from  such  a  source  could  only  arise  at  the  proximal  ranges  when 
the  bullet  makes  an  irregular  impact.  Near  shots  are  uncommon 
among  war  wounds  now,  they  are  more  often  the  result  of  accident. 


GUNSHOT    WOUNDS    OF   JOINTS  297 

(2)  Primary  Excision.^For  the  same  reasons  that  primary  amputa- 
tion has  wellnigh  disappeared  from  the  field  of  military  surgery, 
primary  excision  for  gunshot  of  the  larger  joints  is  correspondingly 
rare.  Except  the  removal  of  pieces  of  comminuted  bone  from 
wounds  caused  by  shell  fragments  or  shrapnel  balls,  nothing  in  the 
nature  of  an  excision  is  done. 

The  knee  and  elbow  maj^  and  do  sometimes  require  secondary 
excision,  at  a  remote  period,  to  correct  faulty  positions  or  ankylosis, 
but  beyond  this,  formal  excisions  for  the  ulterior  effects  of  gunshot  are 
seldom  done  in  war  hospitals. 

(3)  Conservative  Treatment. — Before  the  days  of  antiseptic  treat- 
ment and  the  use  of  the  new  armament  the  recognized  mode  of  treat- 
ment of  joint  wounds  was  by  primary  amputation.  Of  the  two  fac- 
tors that  have  brought  about  the  present  change  in  the  treatment 
of  joint  wounds,  it  is  difficult  to  state  which  of  the  two  should  receive 
the  most  credit.  Joint  wounds  by  the  reduced-cahber  bullets  are 
generally  so  tri^dal,  as  far  as  the  injury  to  cancellous  tissue  is  con- 
cerned, that  beyond  a  clean-cut  perforation  that  heals  in  a  few  weeks 
under  proper  immobilization,  the  lesion  has  no  characteristic  feature 
worthy  of  mention.  The  external  wounds  generally  heal  under  a 
scab  and  although  a  clean  dressing  is  apphed  to  the  surface,  it  is 
doubtful  if  it  plays  much  of  a  part  in  securing  the  primary  healing  that 
takes  place  in  nearly  all  cases.  At  the  same  time  that  we  would  under 
no  circumstances  minimize  the  use  of  a  clean  dressing,  we  are  very 
much  of  the  opinion  that  the  happy  outcome  of  joint  wounds  under 
present  conditions  comes  more  from  the  humane  nature  of  the  lesion, 
and  immobilization,  than  from  anything  else. 

In  joint  injuries  by  the  large-caliber  bullets,  and  other  missiles, 
which  inflict  more  or  less  comminution,  the  antiseptic  details  necessary, 
no  doubt,  play  a  great  role  in  saving  limbs,  and  for  these  cases  we 
would  ascribe  the  greatest  amount  of  credit  to  antiseptics. 

The  Spanish-American  and  Boer  Wars,  in  a  practical  manner, 
plainly  demonstrated  the  humane  nature  of  joint  wounds  by  the  new 
miUtary  rifle,  but  we  are  happy  to  state  that  among  the  experimenters,^ 
we  were  among  those  who  foretold  the  outcome  of  joint  wounds  exactly 
as  we  flnd  it  to-day. 

In  cases  of  simple  wounds  of  the  synovial  membrane  and  clean 
perforations  of  the  epiphyseal  ends  of  bones  the  conservative  manage- 
ment of  a  joint  wound  comprises  the  use  of  a  clean  dressing  applied 

1  Report  Surgeon  General,  U.  S.  Army,  1893. 


298  GUNSHOT   WOUNDS 

to  as  clean  a  field  as  one  can  obtain.  Next  the  i3arts  should  be 
immobilized  in  a  position  to  secure  a  useful  limb  should  anchylosis  occur. 
Passive  movements  and  gentle  massage  should  be  practised  as  soon 
as  the  external  wounds  have  entirely  healed.  Probing  or  any  kind 
of  exploration  is  not  permissible. 

In  joint  injuries  exhibiting  comminution  of  a  moderate  or  severe 
kind,  with  lesion  short  of  the  destruction  of  soft  parts,  demanding 
primary  amputation,  experience  has  shown  that  the  conservative 
method  is  still  worth  while.  Such  cases  are  only  likely  to  arise  from 
shell  fragments,  shrapnell  balls,  and  proximal  shots  by  the  new 
military  rifle.  Except  in  cases  in  which  the  soft  parts  are  badly 
damaged  with  interference  of  the  blood  and  nerve  supply,  conserva- 
tion, even  though  fragmentation  is  well  pronounced,  will  yield  useful 
limbs,  if  careful  antiseptic  treatment  is  persistently  and  rigidly  carried 
out.  These  cases,  unlike  the  more  simple  injuries  to  joints,  require 
exploration,  removal  of  loose  fragments,  irrigation,  drainage,  and 
immobilization. 

In  the  emergent  conditions  of  active  campaign  the  military 
surgeon  is  often  handicapped  in  carrying  out  all  the  painstaking  details 
necessary  to  insure  conservation.  If  he  finds  that  he  cannot  maintain 
extension  and  counter-extension,  and  proper  immobilization,  because 
of  enforced  transport  over  any  and  all  kinds  of  roads  in  unstable 
vehicles,  he  will  then  have  to  consider  the  question  of  primary  amputa- 
tion as  a  preferable  alternative.  Conditions  of  this  kind  are  practi- 
cally unknown  to  our  civil  confreres,  but  they  are  common  enough  with 
us,  and  for  that  reason  military  surgeons  are  often  compelled  to 
sacrifice  limbs — lower  limbs  especially — that  could  be  easily  saved 
in  fixed  hospitals.  An  amputated  limb  will  stand  transport  better 
than  a  comminuted  joint,  and  the  danger  to  life  is  far  less  by  practising 
primary  amputation. 

If  suppuration  should  take  place  in  a  joint  while  the  surgeon  is 
practising  the  conservative  method,  he  should  make  free  incisions  in 
the  dependent  parts  with  liberal  drainage  and  free  irrigation  of 
antiseptic  solutions  of  suitable  strength  twice  per  day. 

Gunshot  Wounds  in  the  Shoulder. — The  wounds  of  this  joint  are 
necessarily  often  accompanied  with  wounds  of  adjacent  parts  like  the 
clavicle,  scapula,  thorax,  neck, face,  forearm  and  hand.  The  projectile 
may  enter  the  joint  from  the  immediate  front  or  from  a  lateral  direc- 
tion. Wounds  of  the  shoulder  are  often  received  in  this  way  but  do 
not  often  implicate  the  joint  proper  and  we  may  add  further  that  gun- 


GUNSHOT   WOUNDS    OF   JOINTS  299 

shot  wounds  involving  the  joint  have  diminished  in  frequency  with 
the  introduction  of  the  small-caliber  military  rifle.  The  reason  for 
this  is  obvious.  The  largest  calibers  of  the  old  armament  were 
themselves  almost  as  large  as  the  globular  head  of  the  humerus,  so 
that  a  hit  in  the  vicinity  of  the  joint  was  correspondingly  more  apt 
to  open  its  capsule  or  cause  lesion  of  its  bony  structure. 

The  statistics  of  former  wars  showed  that  gunshot  of  the  shoulder- 
joint  constitutes  2  per  cent,  of  all  wounds  and  16  per  cent,  of  all  joint 
wounds.  From  our  Civil  War  Otis  reports  1400  cases  of  gunshot 
wounds  of  the  shoulder-joint.  In  seventy-two  of  these  there  was  no 
injury  to  bone.  They  were  treated  expectantly  with  a  mortality  of 
8  per  cent.  In  1328  the  articular  extremity  of  the  humerus  or 
scapula  was  primarily  involved.  In  50  per  cent,  of  the  cases  excision 
of  the  head  of  the  humerus  was  practised;  the  expectant  plan  of 
treatment  was  followed  in  37.50  per  cent,  and  amputation  was 
done  in  12.50  per  cent.  The  general  mortality  was  nearly  33 
per  cent. 

In  4919  gunshot  wounds  recorded  in  the  Annual  Report  of  the 
Surgeon  General  for  1900  occurring  in  the  Spanish-American  War  and 
Philippine  Insurrection  there  were  nine  gunshots  of  the  shoulder-joint 
with  one  death,  the  immediate  cause  of  which  is  not  stated.  Four 
of  the  cases  were  restored  to  duty,  one  was  discharged  at  expiration 
of  term,  and  the  other  three  were  discharged  and  pensioned.  The 
wounds  were  the  result  of  rifle  bullets  as  follows :  4  Mauser,  3  Reming- 
ton, 1  Krag-Jorgensen  and  1  bullet  not  specified. 

The  amount  of  destruction  that  occurs  in  fracture  of  the  bones 
entering  into  the  formation  of  the  shoulder-joint  depends  primarily 
on  the  sectional  area  of  the  bullet  at  the  time  of  impact  and  next  upon 
its  remaining  velocity. 

The  jacketed,  present-day  rifle  bullet  perforates  or  grooves  the 
cancellous  tissue  of  the  anatomical  neck,  the  lesion  depending  upon 
the  angle  of  impact  with  the  globular  head.  In  either  case  there  is 
little  or  no  tendency  to  fissures.  Formerly  larger-caliber  lead  bullets 
caused  great  comminution  of  the  globular  head  of  the  humerus.  Even 
in  shots  which  struck  the  anatomical  neck  at  a  tangent,  there  was  not 
the  tendency  to  gutter  that  there  is  with  armored  bullets. 

A  projectile  striking  the  humerus  at  the  junction  of  the  anatomical 
and  surgical  necks  will  cause  comminution  of  the  globular  head  or 
separate  it  from  the  shaft.  The  separation  will  take  place  in  the 
epiphyseal  junction,  thereby  cutting  off  its  blood  supply,  and  incur 


300  GUNSHOT   WOUNDS 

liability  to  necrosis.  Delorme  was  among  the  first  to  point  out  this 
particular  lesion. 

When  the  projectile  hits  the  surgical  neck  fissures  will  extend 
above  to  the  globular  head  and  below  into  the  shaft  and  the  comminu- 
tion will  be  more  extensive  because  the  resistance  of  the  compact  bone 
in  the  surgical  neck  is  greater.  In  such  cases  the  upper  fragment 
remains  adherent  to  the  periosteum  and  soft  parts  and  furthermore  it 
retains  its  blood  supply,  a  condition  which  insures  ultimate  union  of 
the  fragments. 

Some  writers,  Chenu  among  them,  have  reported  the  rare  occur- 
rence of  dislocation  of  the  head  of  the  humerus  as  a  complication  of 
gunshot  of  the  shoulder-joint. 

Injury  to  the  head  and  neck  of  the  scapula  are  rare  and  when  hit 
by  armored  bullets  they  are  generally  grooved  or  perforated.  Lead 
balls  and  shrapnel  may  cause  extensive  comminution. 

Treatment. — In  cases  of  simple  capsular  wounds  and  perforations 
of  the  anatomical  neck  or  head  of  the  scapula  the  wounds  and  sur- 
rounding surface  should  be  asepticized  with  antiseptic  solutions  or  tinc- 
ture of  iodine.  An  antiseptic  pad  should  be  placed  in  the  axilla  and 
side  of  the  chest.  The  arm,  fore-arm  and  hand  should  be  secured  to 
the  side  and  front  of  the  chest  by  a  wide  roller  bandage.  No  undue 
amount  of  examination  to  ascertain  the  extent  of  injury  should  be 
made.  This  can  be  later  ascertained  by  X-ray  examinations.  Ex- 
ploration by  finger  or  instruments  is  not  permissible. 

When  fracture  by  larger  bullets  or  shell  fragments  occurs  with 
comminution  the  management  of  the  case  has  to  be  considered 
under  the  plans  of  (a)  Conservative  treatment,  (b)  Excision  or  (c) 
Amputation. 

(a)  Conservative  Treatment. — This  method  should  be  practised 
in  any  kind  of  injury  with  comminution,  short  of  destruction  of  the 
great  vessels  and  nerves  supplying  the  upper  extremity.  Later,  if 
conservation  fails,  secondary  excision  or  amputation  can  be  performed 
with  very  little  if  any  additional  risk  to  life.  If  deemed  advisable  a 
thorough  examination  under  a  general  anesthetic  may  be  made  to 
ascertain  the  amount  of  injury  and  for  the  removal  of  loose  fragments. 
In  this  examination  the  wounds  may  be  enlarged  to  facilitate  the  ex- 
ploration and  subsequent  drainage.  No  fragment  should  be  removed 
unless  it  is  found  to  be  entirely  isolated. 

Irrigation  with  boric-acid  solution  or  a  1-4000  solution  of  bichloride 


GUNSHOT   WOUNDS    OF   JOINTS 


301 


of  mercury  should  next   be  made,  drainage  provided  for,  and  after 
applying  a  clean  dressing  the  limb  should  be  immobilized. 

From  50  to  60  per  cent,  of  gunshots  of  the  shoulder  treated  by  the 
conservative  method  recover  with  partial  or  complete  anchylosis  and 
for  this  reason  massage  and  passive  motion  should  be  practised  early — 
as  soon  as  the  external  wounds  have  healed.     (Figure  133.) 


Fig.  133. — Skiagram  showing  the  result  of  gun-shot  by  the  .30  cal.  Krag-Jorgensen  bullet  in  a 
U.  S.  soldier  who  was  shot  at  a  distance  of  5  feet,  in  Oct.,  1901.  He  was  treated  in  accordance  with 
modern  methods  by  removing  all  detached  fragments,  etc.  There  is  excellent  use  of  the  arm. 
Exposure  was  made  in  1911.     Lettermann  General  Hospital  Laboratory. 

(b)  Excision. — ^Before  the  days  of  antisepsis  and  the  change  in  the 
armament  primary  excision  was  the  favorite  method  of  treatment  in 
nearly  all  wounds  of  the  shoulder-joint  implicating  its  bony  structures. 
Surgeons  found  by  "^dde  experience  that  their  formal  excisions,  which 
were  done  with  a  view  to  removal  of  all  fragments  and  most  of  the 
lacerated  tissues,  left  a  comparatively  clean  operative  wound  which 
was  not  so  prone  to  the  development  and  spread  of  infection  as  the 
original  wound  caused  by  the  crashing  effects  of  the  projectiles  of 


302 


GUNSHOT   WOUNDS 


that  day.     For  this  reason  excisions  were  more  popular  than  attempts 
at  conservation.     (Figure  134.) 

Now  that  we  ward  off  sepsis  by  antiseptic  methods  and  that  the 
character  of  the  wounds  has  become  less  grave,  formal  primary 
excisions  are  not  required.  No  operative  interference  is  done  except 
occasionally  to  remove  loose  fragments  of  bone,  missiles  and  lodged 
pieces  of  clothing. 

When  suppuration  sets  in  with 
sepsis  as  a  result  of  necrosis  in  and 
about  the  joint  in  cases  where  at- 
tempts at  conservation  have  failed, 
secondary  excision  is  in  order.  The 
excision  should  be  thorough,  and 
effective  drainage  with  persistent 
irrigation  should  be  employed.  By 
adopting  this  plan  of  treatment  the 
arm  will  be  saved  and  amputation 
avoided. 

Amputation. — As  stated  already 
primary  amputation  is  indicated 
for  severe  comminution  of  the 
bones  entering  into  the  formation 
of  the  joint,  with  extensive  lacera- 
tion of  the  soft  parts,  and  injury  to 
the  large  vessels  and  nerves.  Sec- 
ondary amputation  sometimes  be- 
comes necessary  in  attempts  at 
conservation  when  osteomyelitis, 
gangrene  or  secondary  hemorrhage 
appear  as  complications.  Necrosis 
of  a  large  portion  of  the  humerus 
was  a  cause  of  amputation  at  the  shoulder  in  preantiseptic  days  and 
the  same  may  be  said  of  long-continued  suppuration  in  the  joint. 
The  greater  number  of  the  causes  mentioned  will  seldom  be  met  with 
when  our  modern  methods  of  treatment  have  been  followed. 

Gunshot  Wounds  of  the  Elbow. — The  wounds  of  this  joint  average 
from  1.5  to  2  per  cent,  of  all  wounds  in  war,  and  35  per  cent,  of  all 
joint  wounds.  The  frequency  of  gunshot  of  the  elbow  ranks  next  to 
that  of  the  knee. 

The  amount  of  lesion,  as  well  known,  is  proportional  to  the  sectional 


Fig.  134. — A  recent  radiogram  showing  ex- 
cision in  the  case  of  Benj.  R.  Pratt,  an  ex- 
volunteer  soldier  who  was  shot  in  the  shoulder 
in  the  Civil  War  in  1863.  Character  of  mis- 
sile unknown.  Army  Medical  School  collec- 
tion. 


GUNSHOT   WOrXDS    OF   JOINTS  303 

area  of  the  projectile  on  impact.  With  the  use  of  the  older  military 
rifle  as  well  as  shots  from  shrapnel  and  pieces  of  shells  there  is  much 
damage  to  osseous  structures  entering  into  the  formation  of  the  joint. 
Smaller  projectiles,  and  especially  the  jacketed  present-day  bullets, 
inflict  injuries  that  are  more  often  circumscribed  and  restricted. 
Antero-posterior  shots  groove  the  prominence  of  the  condyles  of  the 
humerus  or  perforate  the  epitrochlear  notch  with  little  Assuring. 
Contact  shots — shots  in  which  the  impact  of  the  bullet  is  conveyed  to 
the  articular  end  of  the  humerus  without  causing  more  than  slight 
grazing — sometimes  show  separation  of  the  epiphysis  from  the  shaft, 
as  in  simple  fracture.  Shots  disposed  transversely  through  the 
epiphyseal  junction  badl}^  comminute  the  lower  fragment  into  the 
joint. 

Injuries  to  the  head  of  the  radius  consist  of  grooves  and  perfora- 
tions, and  when  the  ball  strikes  toward  the  shaft,  away  from  the 
epiphyseal  junction,  a  fracture  with  fissures  occurs,  such  as  one  is  apt 
to  find  in  injuries  to  diaphj^ses  generally. 

Shots  through  the  joint  which  involve  the  ulna  rarely  cause 
complete  separation  of  the  fragments.  They  partake  more  of  the 
nature  of  grooves  and  perforations.  Transverse  shots  at  the  base  of 
the  olecranon  are  apt  to  show  long  fissures  into  the  shaft,  while  antero- 
posterior shots  through  the  olecranon  proper  exhibit  perforation  wdth 
radiating  fissures  above  and  below,  with  fragments  held  together. 

Taken  as  a  whole  gunshot  lesions  of  the  elbow-joint  lend  themselves 
specially  to  the  conservative  method  of  treatment. 

Conservation. — This  method  of  treatment,  like  all  the  operative 
measures  had  its  share  of  mortality  in  preantiseptic  times.  Otis 
records  a  mortality  of  10.3  per  cent,  in  our  Civil  War.  This  was 
slightly  lowered  in  the  Franco-German  War  of  1870-71,  viz.,  9.8  per 
cent. 

With  the  advent  of  antisepsis  conservation  has  become  the  method 
of  choice  in  all  injuries  of  the  elbow  save  the  few  which  from  the 
extreme  amount  of  traumatism  to  bone  and  soft  parts  demand  primary 
excision  or  primary  amputation.  Conservation  is  to  be  practised  in 
all  synovial  wounds  and  all  bone  injuries  like  those  to  the  articular 
ends  of  the  humerus,  ulna  and  radius  already  mentioned.  As  long  as 
the  nerve  and  blood  supply  are  not  entirelj^  destroyed,  no  matter  what 
the  bone  lesion  may  be,  there  is  hope  of  a  useful  hand,  which  is  after 
all  the  great  desideratum,  and  conservation  should  be  tried.  Con- 
servation is  only  contraindicated  by  traumatism  of  the   joint  com- 


304  GUNSHOT   WOUNDS 

plicated  by  injury  to  the  brachial  artery;  and  yet  in  preantiseptic 
times  some  of  the  leading  surgeons,  notwithstanding  the  gravity  of 
such  extensive  traumatism,  essayed  conservation,  and  sometimes  suc- 
ceeded. In  these  daring  attempts  they  pinned  their  faith  on  the 
abundant  opportunity  for  collateral  circulation  that  is  normally 
present  about  the  elbow. 

When  we  remember  that  the  rules  of  conservation  as  they  are 
now  taught  were  established  in  preantiseptic  times,  we  are  all  the  more 
hopeful  of  its  value  under  our  present  methods  of  wound  treatment. 
One  should,  however,  remember  that  conservation  in  the  extreme 
traumatisms  referred  to — those  implicating  the  blood  supply — find  no 
application  in  active  campaign  when  transport  is  impending.  Con- 
servation with  a  precarious  blood  supply  is  apt  to  be  attended  by 
gangrene,  an  eventuality  that  requires  watchful  care,  and  an  amount 
of  attention  that  can  seldom  be  bestowed,  except  in  fixed  hospitals. 
In  such  cases  the  military  surgeon  is  often  compelled  to  advise  ampu- 
tation when  his  civil  confrere  is  able  to  save  a  limb. 

Although  the  aim  of  the  surgeon  at  conservation  is  directed  toward 
a  movable  joint,  the  experience  of  war  surgery  affords  but  little  en- 
couragement for  such  an  outcome.  Otis  records  but  three  cases  with 
good  motion  in  our  Civil  War,  the  majority  recovered  with  true  bony 
anchylosis.  Audet^  found  in  1135  cases  of  gunshot  of  the  elbow  from 
various  sources  but  2.5  per  cent,  with  good  motion.  Following  the 
Franco-German  War  of  1870-71  out  of  163  cases  Dominick  found 
complete  anchylosis  in  82.8  per  cent.,  partial  anchylosis  in  11  per 
cent,  and  good  motion  in  6.2  per  cent. 

We  will  expect  better  results  in  cases  where  suppuration  is  avoided 
hereafter.  This  will  be  especially  so  in  those  cases  of  injury  to  the 
synovial  membrane  alone,  and  the  lesser  bone  injuries.  The  function 
of  pronation  and  supination  will  be  retained  in  cases  where  the  head 
of  the  radius  and  its  articulating  surface  escape  injury  notwithstanding 
the  occurrence  of  anchylosis  in  other  parts  of  the  joint. 

In  the  recent  wars  of  which  we  have  record  nearly  all  cases  were 
treated  by  conservation.  Out  of  forty-four  cases  of  gunshot  of  the 
elbow-joint  in  the  Spanish- American  War  the  mortality  was  2.2  per 
cent,  and  in  the  Boer  War  out  of  forty-nine  reported  cases  there  was 
one  death  following  amputation. 

In  conducting  conservation  of  elbow  cases  the  limb  should  be 
fixed  in  a  position  that  will  give  the  greatest  use  of  the  hand  should 

^  Audet,  Manuel  de  Chinergie  d'armee,  Paris,  1886. 


GUNSHOT    WOUNDS    OF   JOINTS  305 

anchylosis  result.  To  this  end  the  forearm  is  flexed  on  the  arm  at 
a  trifle  less  than  a  right  angle  and  the  hand  should  occupy  a  position 
half  way  between  pronation  and  supination,  the  thumb  pointing 
upward.  The  fixation  apparatus  should  be  so  placed  as  to  permit 
redressing  of  the  wound  without  disturbing  in  any  way  the  attempt 
at  immobilization. 

Exploration  of  the  wound  is  only  necessary  in  cases  showing  com- 
minution of  the  articular  ends  of  bones.  In  such  cases  the  external 
wounds  should  be  enlarged  if  necessary,  or  the  joint  may  be  exposed 
by  a  posterior  and  external  incision  running  in  the  axis  of  the  limb. 
All  sphnters  and  fragments  of  bone,  pieces  of  clothing  and  missiles 
should  be  removed.  The  joint  and  wound  should  be  irrigated  thor- 
oughly with  a  weak  bichloride  solution  1  to  4000.  Drainage  should 
be  maintained  for  a  few  days. 

The  occurrence  of  infection  should  be  met  by  thorough  drainage 
and  frequent  irrigation,  and  if  it  persists  secondary  excision  will  have 
to  be  considered. 

In  less  serious  cases,  where  there  is  reason  to  suspect  slight  bony 
lesion,  no  exploration  of  any  kind  should  be  undertaken.  Such 
cases  require  a  clean  dressing  applied  to  a  clean  field,  and  fixation. 
In  cases  which  progress  to  a  successful  termination  without  evidence 
of  inflammation  early  passive  motion  should  be  practised.  The  time 
to  commence  passive  motion  will  vary,  but  it  should  not  be  carried 
on  to  any  extent  before  the  healing  of  the  external  wounds. 

Excision  of  the  Elbow. — No  primary  excision  of  the  elbow  was 
done  during  either  the  Spanish-American  or  Boer  War  and  such  an 
operation  will  seldom  be  required  in  the  war  surgery  of  the  future. 

The  operation  is  indicated  in  those  cases  that  show  comminution 
on  exploration,  with  fragments  entirely  detached.  If  operation  be- 
comes imperative,  the  weight  of  opinion  at  present  favors  a  radical 
rather  than  a  modified  excision.  The  mere  removal  of  fragments  is 
usually  followed  by  anchylosis  and  the  end  results  are  not  good. 
Provided  the  injuries  to  soft  parts  and  nerves  are  not  as  extensive 
as  to  incur  flail  joint  or  useless  hand,  a  complete  excision  is 
preferable. 

Complete  bony  anchylosis  of  the  elbow  is  very  trying.  It  often 
leads  to  the  necessity  for  excision  at  a  remote  period,  the  results  of 
which  are  generally  satisfactory.  Complete  primary  excision  is  there- 
fore the  operation  of  choice  whenever  the  lesion  requires  excision  at 
all.     In  support  of  this  view,  the  experience   of  the  older  surgeons 


306  GUNSHOT   WOUNDS 

serves  us  in  good  stead.  We  know  the  value  of  primary  excisions  of 
the  elbow,  as  far  as  the  use  of  the  arm  and  hand  are  concerned,  by  their 
statistics  which  are  abundant.  According  to  Gurlt  the  statistics  of 
primary  excision  after  the  Franco-German  War  of  1870-71  were 
"good"  in  29  per  cent,  of  the  cases,  "moderate"  in  53  per  cent.,  and 
"bad"  in  17  per  cent.  Otis  reporting  upon  complete  excision  in 
our  Civil  War  states  that  "a  fair  proportion  retained  a  fair  amount 
of  control  over  the  uses  of  the  forearm  and  hand,  a  smaller  number 
had  very  serviceable  limbs,  and  in  a  few  instances  the  usefulness  of  the 
limbs  was  hardly  at  all  impaired."  The  Civil  War  surgeons  were 
deterred  from  doing  complete  excision  because  of  the  mortality  which 
attended  operative  procedures  in  that  day.  In  the  class  of  cases  de- 
manding excision,  we  should  expect  no  mortality  of  any  consequence 
in  the  future  and  the  functions  of  the  limb  will  no  doubt  be  better  pre- 
served than  they  have  been  hitherto. 

Complete  primary  excision  is  not  to  be  recommended  in  gunshot 
of  other  joints,  but  for  the  reasons  mentioned  we  believe  that  excisions 
of  the  elbow  in  the  class  of  badly  comminuted  fractures  mentioned 
will  find  favor  in  the  wars  of  the  future. 

Secondary  Excision. — This  procedure  will  seldom  be  required 
when  the  wound  treatment  has  been  properly  carried  out.  In  pre- 
antiseptic  times  it  was  necessarily  frequently  done  as  a  measure  to 
save  life  when  active  inflammation  had  set  in  after  attempts  at  con- 
servation. Persistent  chronic  arthritis  and  necrosis  were  also  among 
the  later  causes  of  secondary  excision,  and  then  excision  was  practised 
at  a  remote  period.  When  the  muscles  remain  in  good  functional 
condition  excellent  results  are  obtained  from  excisions  at  a  remote 
period.  Stevenson's  experiences  in  such  cases  were  exceptionally  good 
after  the  Tirah  Expedition  and  Boer  War.  He  states  that  "all  of  the 
cases  operated  on  were  improved  and  in  some  of  them  flexion  and  ex- 
tension were  as  complete  as  could  be  desired  while  the  limb  and  new 
joint  were  strong  and  useful."  If  the  case  requires  removal  of  the 
articular  ends,  the  less  bone  taken  away  the  better.  The  cases  require 
persistent  and  continued  attempts  at  passive  motion,  massage  and 
electricity. 

Primary  amputation  of  the  elbow  is  done  as  in  other  joint  injuries 
when  extensive  injury  to  bone  and  soft  parts  is  present  with  involve- 
ment of  nerve  trunks.  Injuries  to  the  brachial  and  its  branches  which 
threaten  the  occurrence  of  gangrene  are  debatable  causes  for  amputation. 
The  rich  collateral  circulation  about  the  elbow  often  makes  it  worth 


GUNSHOT    WOUNDS    OF   JOINTS  307 

while  to  attempt  the  saving  of  a  limb  if  the  remaining  lesions  are  of  a 
character  to  warrant  the  effort. 

Secondary  Amputation. — The  old-time  common  sequelse  and 
complications  of  gunshot  wounds  like  osteomyelitis,  necrosis  and 
secondary  hemorrhage,  were  rather  frequent  causes  for  amputation  in 
gunshot  of  the  elbow.  The  more  common  causes  of  secondary  am- 
putation now  are  for  limbs  that  have  become  useless  appendages  as  a 
result  of  the  successful  practice  at  antisepsis. 

Gunshot  Wounds  of  the  Wrist  and  Carpus. — Gunshot  of  the  wrist 
was  not  specially  fatal  in  former  wars.  Otis  makes  out  a  mortality 
of  12.9  per  cent,  out  of  1496  shot  fractures  of  the  bones  of  the  wrist 
after  all  plans  of  treatment,  like  conservation,  the  various  excisions, 
and  amputations  incident  to  severe  lesions  or  complications  like 
inflammation,  sepsis,  etc. 

The  lesions  of  the  joint  from  gunshot  will  depend  upon  the  size  of 
the  projectile.  Frightful  lacerations  will  occur  from  shell  fragments, 
and  shrapnel  balls  hitting  the  joint  in  a  transverse  or  oblique  direction. 
Lead  balls  from  pistols  or  rifles  shatter  the  lower  end  of  the  radius  or 
ulna  into  the  joint  causing  fissures  to  extend  into  the  diaphysis.  The 
first  or  second  rows  of  carpal  bones  may  be  injured  by  dorso-palmar, 
oblique  or  transverse  shots.  Injury  to  the  lower  end  of  the  radius  and 
ulna  implicating  the  joint  is  the  most  frequent  lesion  found,  and  the 
dorso-palmar  direction  is  less  harmful  to  the  anatomical  structures 
than  the  transverse  or  oblique  perforations. 

The  effects  of  the  modern  bullet  of  small  caliber  are  less  likely  to 
comminute  the  joint  ends  of  the  ulna  and  radius  or  the  carpal  bones. 
They  groove  and  perforate  the  former  and  only  shatter  the  carpal  bones 
which  they  strike.  They  do  not  divide  tendons  nor  lacerate  tissues  as 
the  old  lead  bullets  did,  hence  the  danger  of  sepsis  is  naturally  not  so 
great.  No  deaths  are  reported  from  the  Spanish-American  or  Boer 
War. 

Conservative  Treatment. — This  method  of  dealing  with  gun-shot 
fractures  of  the  wrist  has  been  practised  since  the  days  of  Pare  and 
it  is  more  applicable  to-day  than  ever  before.  From  our  Civil  War, 
and  the  Franco-German  War  of  1870-71,  Otis  and  Screven  report  a 
mortahty  after  the  conservative  plan  of  treatment  of  7.6  per  cent,  and 
11.4  per  cent.,  respectively. 

The  results  of  conservation  to  the  function  of  the  hand  and  fingers 
are  very  much  influenced  by  the  presence  of  inflammation  in  the  wound. 
In  the  preantiseptic  era  when  infection  of  all  wounds  was  the  rule, 


308  GUNSHOT   WOUNDS 

the  patients  recovered  with  anchjdosis  in  the  large  majority  of  cases. 
But  few  soldiers  recovered  with  function  of  the  hand  and  fingers 
sufficiently  preserved  to  enable  them  to  return  to  the  ranks.  Out 
of  307  cases  in  the  Franco-German  War  Screven  found  264  or  82.4  per 
cent,  who  recovered  with  complete  anchylosis,  and  hands  more  or  less 
useless,  and  56  or  14.6  per  cent,  with  incomplete  anchylosis  and  slight 
use  of  the  hand.  In  the  same  war  Gurlt  out  of  sixteen  wounded 
treated  conservatively  found  but  one  retaining  the  function  of  the 
hand  sufficiently  to  permit  him  to  be  restored  to  duty.  In  our  Civil 
War  out  of  fifty-eight  gunshot  of  the  wrist  fifty-one  recovered  with 
anchylosis  of  the  wrist,  five  ^dth  mobility  marked  by  deformity,  and 
three  with  flail  joint.  These  disabilities  were  almost  entirely  the  result 
of  adhesions  in  the  joints  and  tendon  sheaths  as  a  result  of  inflam- 
matory exudate. 

Under  our  present  plan  of  wound  treatment,  which  is  directed 
toward  the  prevention  of  sepsis,  in  gunshot  of  the  wrist  of  the  less 
severe  type,  there  should  be  no  serious  loss  of  function  in  the  hand. 
The  experience  in  the  Spanish-American  and  Boer  Wars  fully  justifies 
this  statement,  and  the  same  will  no  doubt  apply  to  the  results  in  the 
Manchurian  campaign  when  the  official  reports  become  accessible. 

In  the  minor  degrees  of  injury  the  wounds  should  be  enlarged  if 
necessary  and  loose  fragments  of  bone  removed.  Irrigation  of  the 
wound  and  synovial  sac  should  next  be  thoroughly  done,  drainage 
provided  for,  and  the  limb  immobilized,  in  a  clean  dressing,  with  the 
elbow  slightly  flexed. 

The  appearance  of  suppuration  in  the  joint  at  any  time  during 
the  treatment  should  be  met  by  free  incisions  on  the  sides  of  the  wrist, 
to  forestall  abscess  formations  up  the  arm.  When  the  joint  has  been 
cut  into,  additional  exploration  should  be  made  for  loose  fragments 
of  bone  and  if  necessary  a  partial  secondary  excision  may  be  made. 
Unfortunately  the  results,  when  extensive  inflammation  occurs  and 
partial  secondary  excision  is  required,  are  not  very  encouraging  as  to 
the  ultimate  function  of  the  wrist  and  fingers.  Such  cases  only  too 
often  end  in  grip-hand  which  is  not  much  better  than  no  hand  at  all. 

Primary  Excision  of  the  Wrist. — Complete  and  partial  excision  of 
the  wrist  for  gunshot  gave  discouraging  results  in  preantiseptic  times. 
Otis  relates  six  cases  of  complete  primary  excisions,  one  ending  fatally 
after  amputation.  The  other  five  recovered  with  impaired  function 
of  the  hand,  "but  all  things  taken  into  consideration,  in  a  better  con- 
dition than  if  they  had  been  subjected  to  amputation."     If  those 


GUNSHOT   WOUNDS    OF   JOINTS  309 

were  the  results,  and  the  impression  of  the  utility  of  the  hand  after 
complete  excision  in  preantiseptic  times,  the  outcome  that  must  ob- 
tain henceforth  should  be  more  encouraging  still.  Complete  primary 
excision  is  only  required  for  wounds  caused  by  shell  fragments  or  lead 
balls  which  cause  much  disorganization  of  the  bony  articulation. 
Smaller  projectiles  and  shots  from  reduced-caliber  rifle  bullets  in  any 
but  proximal  ranges  will  cause  less  fragmentation,  and  as  this  class  of 
wrist  wounds  ^dll  form  the  larger  number,  partial  primary  excisions 
will  be  required  in  the  great  majority  of  cases. 

In  our  Civil  War  partial  primary  excision  and  secondary  excisions 
gave  twice  the  mortality  observed  after  the  conservative  plan  of  treat- 
ment. Sepsis  played  a  great  role  in  this  outcome.  The  same  may 
be  said  of  the  results  concerning  the  utility  of  the  hand.  In  the 
Franco-German  War  Gurlt  found  the  end  results  in  partial  excision 
"good"  in  6.25  per  cent,  of  the  cases,  and  ''moderate,"  "bad"  and 
"very  bad"  in  93.75  per  cent. 

Shots  from  the  modern  rifle  bullet  will  not  as  a  rule  cause  much 
impairment  of  the  wrist-joint.  The  bone  lesion  will  be  marked  by 
perforation  or  slight  guttering  of  the  articular  ends  of  the  ulna  and 
radius,  which  will  heal  aseptically  in  the  large  majority  of  the  cases. 
Mr.  Makins  "never  saw  any  trouble  result  from  perforations  of  the 
carpus"  in  the  Anglo-Boer  War.  Secondary  excision  becomes  neces- 
sary when  sepsis  as  a  complication  makes  its  appearance  in  joints 
undergoing  conservative  treatment.  The  surgeon  will  have  to  decide 
whether  partial  or  complete  excision  is  to  be  employed. 

In  the  after-treatment,  fixation  should  be  maintained  in  such  a 
way  as  to  permit  passive  motion  of  the  thumb  and  fingers.  Wadding 
should  be  placed  between  the  thumb  and  index  finger  to  prevent  the 
former  from  becoming  more  or  less  anchylosed  next  to  the  latter. 
Passive  motion  of  the  digits  should  be  commenced  in  a  day  or  two 
and  maintained  along  with  massage  and  faradization  all  through 
convalescence  and  longer.  The  utility  of  the  hand  depends  almost 
entirely  on  the  attention  thus  bestowed. 

Primary  amputation  is  only  required  after  extensive  lesion  to  the 
soft  parts  and  bony  articulation  from  shell  fragments,  larger  rifle 
projectiles,  and  wounds  by  fine  and  coarser  pellets  out  of  shot  guns. 

Gunshot  Wounds  of  the  Hip-joint. — The  frequency  of  gunshot  of 
the  hip-joint  as  determined  by  Fischer  was  thirty  cases  for  every  1000 
wounds  of  all  anatomical  parts,  and  5  per  cent,  of  all  joint  wounds. 

Of  the  injuries  to  the  large  joints  those  of  the  hip  were  the  most 


310  GUNSHOT   WOUNDS 

fatal.  The  diagnosis  was  always  uncertain,  and  oftentimes  obscure, 
and  in  active  campaign  they  were  among  the  most  difficult  to  treat. 
Otis  gives  the  results  in  386  cases  treated  in  the  Civil  War  from  the 
Union  and  Confederate  armies.  Of  this  number,  in  40,  the  part  of 
the  joint  involved  is  not  stated.  The  acetabulum  alone,  or  the  aceta- 
bulum and  some  part  of  the  head,  neck,  or  shaft  of  the  femur  figured  in 
the  lesion  in  seventy-four  cases.  Sixty-four  were  treated  by  conser- 
vation and  but  two  recovered,  the  fatality  being  96  per  cent.  Nine 
were  treated  by  excision,  one  by  amputation,  with  a  mortality  of  100 
per  cent.  The  head  of  the  femur  alone,  or  the  head  and  neck,  the  head, 
neck  and  trochanters,  the  head,  neck  and  shaft,  the  upper  portion 
of  the  femur  or  trochanter  involving  the  joint  were  included  in  the 
lesion  in  272  cases.  Two  hundred  and  three  of  these  were  treated  by 
conservation  with  160  deaths  or  a  fatality  of  58  per  cent,  as  compared 
to  96  per  cent,  for  the  group  which  includes  lesion  of  the  acetabulum 
also.  Out  of  forty-five  excisions  in  the  last  group  forty-three  died,  the 
mortality  being  95  per  cent.  Of  nineteen  cases  subjected  to  ampu- 
tation, with  a  question  as  to  the  result  in  two,  death  occurred  in 
every  case. 

By  dividing  the  cases  in  the  two  groups — one  where  the  acetabulum 
is  implicated  in  the  lesion,  and  the  other  where  it  is  not,  we  find  that 
treatment  by  excision  and  amputation  was  alike  fatal  in  both,  and  that 
treatment  by  conservation  of  the  cases  with  acetabular  involvement 
gave  an  excessive  mortality  as  compared  to  what  we  find  in  articular 
lesion  without  acetabular  involvement,  viz.,  a  mortality  of  96  per 
cent,  as  compared  to  58  per  cent. 

Although  sepsis  might  account  for  a  large  percentage  of  the 
fatalities  in  each  group,  it  cannot  account  for  the  great  divergence  in 
the  mortality  of  the  two  groups,  for  we  must  admit  that  sepsis  arising 
from  lesions  without  acetabular  involvement  should  be  as  fatal  as  that 
arising  with  acetabular  involvement.  The  larger  death  rate  among 
the  acetabular  cases  was  no  doubt  connected  with  adjoining  pelvic 
complications  incident  to  the  crashing  effects  of  the  large  rifle  pro- 
jectiles of  that  period,  and  in  this  sense  the  death  rate  of  this  group 
cannot  be  taken  as  figuring  entirely  in  the  death  rate  of  hip  cases 
alone. 

The  comparatively  low  death  rate  of  58  per  cent,  in  the  second 
group,  viz.,  in  those  cases  showing  lesion  of  the  head,  neck,  alone  or 
combined,  or  shaft,  trochanter,  and  neck  combined  was  not  a  bad 
result  for  that  time  and  mode  of  treatment.     If  such  cases  had  been 


GUNSHOT   WOUNDS    OF   JOINTS  311 

treated  antiseptic  ally,  after  our  present  methods  without  exploration 
with  probes  or  fingers,  except  when  urgently  required,  we  have 
reason  to  believe  that  the  results  would  have  been  exceptionally  good, 
notwithstanding  the  comminution  attending  injuries  by  the  old-time 
projectiles. 

Because  of  the  present-day  tactics  of  firing  in  the  prone  position, 
the  hip-joint  is  not  so  frequently  wounded  as  formerly.  When  the 
soldier  is  lying  down  under  cover  the  hip  is  one  of  the  least  exposed 
parts  of  the  body.  Mr.  Makins  saw  but  one  case — a  grazing  of  the 
edge  of  the  acetabulum — in  the  Anglo-Boer  War.  Stevenson 
reports  seven  cases  in  the  same  war,  and  the  Surgeon-General,  U.  S. 
Army,^  reports  three  cases  as  having  occurred  in  the  Spanish-American 
War. 

Pathology. — The  effects  of  projectiles  on  the  hip-joint  include 
lesion  of  the  (1)  capsule,  (2)  trochanters,  (3)  the  head  of  the  femur, 
(4)  the  neck,  and  (5)  the  portion  of  the  surgical  neck  adjacent  to  the 
intertrochanteric  line. 

(1)  Lesion  in  the  Capsule. — Projectiles  passing  antero-posteriorly 
or  in  the  reverse  direction  can  injure  the  capsule  by  grazing  or  actually 
perforating  its  cavity  opposite  the  head  and  neck  without  implicating 
the  bony  structure.  In  the  same  way  the  capsule  may  be  contused 
and  even  perforated  by  shots  disposed  tranversely  from  without  inward 
or  vice  versa  in  front  or  behind  the  joint  without  implicating  the  osseous 
structure  of  the  articulation  proper.  Otis  refers  to  forty-nine  cases  of 
perforation  of  the  capsule  in  the  Civil  War.  Shots  from  the  modern 
military  rifle  are  especially  apt  to  perforate  the  capsule  without 
implicating  the  bony  parts  of  the  joint.  Injury  to  the  capsule  by  the 
modern  rifle  bullets  with  and  without  bone  lesion  is  more  often  linear 
in  shape,  with  apparently  little  or  no  loss  of  substance. 

(2)  Lesions  of  the  Trochanters. — The  greater  and  lesser  trochanters 
may  suffer  contusion,  grooving  and  complete  perforation  by  pro- 
jectiles traveling  in  any  direction,  with  no  special  tendency  to  fissures 
from  the  point  of  impact.  The  lesion  is  limited  for  the  projectiles  of 
hand  weapons,  but  especially  so  for  jacketed  reduced-caliber  bullets 
in  the  mid  ranges.  The  perforation  by  the  latter  on  entering  is  clean- 
cut,  while  the  lesion  at  the  point  of  exit  is  larger  and  marked  by  the 
presence  of  small  detached  fragments,  with  others  still  attached. 
Fissures,  if  any,  are  more  often  subperiosteal  and  seldom  extend 
beyond  the   limits   of  the   apophyseal  structure.     Lesion  from  the 

1  Reports  of  the  Surgeon  General,  U.  S.  A.,  1899-1901. 

21 


312  GUNSHOT   WOUNDS 

larger-caliber  lead  projectiles  like  those  of  our  .45-caliber  Springfield 
rifle  were  attended  with  much  comminution  and  fissures  extending  to 
the  shaft  and  neck. 

(3)  Lesions  of  the  head  of  the  femur  may  consist  of  contusion, 
slight  grazing,  grooving,  and  perforations  that  are  clean  or  attended 
with  more  or  less  fragmentation  depending  upon  the  sectional  area  of 
the  bullet.  When  the  force  of  impact  is  directed  near  the  epiphyseal 
line  with  the  neck,  there  is  danger  of  separation  of  the  head  from  the 
latter  as  was  pointed  out  in  similar  shots  in  the  shoulder-joint.  The 
lesion  is  more  apt  to  be  circumscribed  or  to  partake  of  the  nature  of  a 
groove  or  perforation  in  shots  from  armored  bullets,  at  medium  ranges. 

(4)  Lesion  of  the  Neck  of  the  Femur. — Traumatism  may  here 
consist  of  contusion  grazing,  grooving  or  complete  perforation  with  or 
without  fissuring.  A  shot  which  grooves  the  circumference  of  the 
neck  is  attended  with  more  or  less  fragmentation,  the  fragments  re- 
maining attached  or  set  free  in  and  about  the  joint  depending  upon  the 
sectional  area,  velocity,  and  density  of  the  projectile.  When  the 
force  of  impact  causing  either  a  groove  or  perforation  is  delivered  at 
either  end  of  the  neck  with  fissuring,  the  latter  will  be  disposed  toward 
the  epiphyseal  line  of  the  end  hit,  causing  complete  or  partial  separation 
of  the  neck,  with  the  head  or  the  trochanteric  region,  as  the  case  may 
be.  One  of  the  larger  rifle  projectiles,  like  that  of  our  .45-cahber 
Springfield  rifle,  striking  the  neck  in  any  part  of  its  circumference  will 
at  times,  through  the  force  of  the  energy  delivered,  cause  fissures  to 
occur  simultaneously  in  the  direction  of  the  epiphyseal  lines  at  both 
ends  of  the  neck,  thus  partially  or  completely  separating  the  latter. 
When  the  vibratory  force  is  delivered  at  about  the  center  of  the  neck 
traversing  it  through  its  thickest  part  the  resulting  traumatism  will 
consist  of  a  clean  perforation  with  more  or  less  fissuring  and  fragmenta- 
tion— hits  by  the  modern  rifle  bullets  will  be  clean-cut  like  those 
which  it  exhibits  through  cancellous  tissue  generally,  while  lesion  of 
larger-caliber  leaden  bullets  will  tend  toward  fissures  and  comminution 
which  will  correspond  in  extent  with  the  sectional  area  and  velocity  of 
the  bullet. 

Diagnosis. — Before  the  introduction  of  the  X-ray  the  diagnosis  of 
gunshot  of  the  hip  was  difficult  and  oftentimes  impossible.  The 
depth  of  the  joint  in  the  tissues  made  exploration  with  the  finger 
through  the  wound  very  difficult.  The  physical  signs  of  fracture  such 
as  shortening  of  the  limb,  eversion  of  the  foot,  disturbed  relations  of 
the  bony  points  about  the  joint,  or  escape  of  synovia  may  be  absent. 


GUNSHOT   WOUNDS    OF   JOINTS  313 

The  joint  is  so  well  supported  by  muscles,  ligaments  and  fascia  that 
severe  injury  to  the  joint  is  possible  when  the  patient  still  retains 
power  of  motion  and  ability  to  walk.  Now  that  the  armored  bullets 
have  come  into  general  use  this  difficulty  in  diagnosis  by  the  old-time 
physical  signs  is  very  much  emphasized.  The  jacketed  bullets  groove 
or  perforate  the  head,  neck  and  trochanters  of  the  femur  almost  in- 
variably. Solution  of  continuity  is  seldom  complete,  and  the  physical 
signs  of  fracture  will  be  absent  as  a  rule.  In  such  cases  one  will  have 
to  rely  on  the  wounds  of  entry  and  exit,  and  take  account  of  the 
tissues  that  have  been  traversed  by  the  course  of  the  straight  line 
between  the  external  wounds.  Again  in  such  cases  hereafter  the 
surgeon  will  have  to  invoke  the  assistance  of  X-ray  evidence  to  set 
him  aright.  Formerly  in  cases  of  doubt  the  surgeon  was  advised  to 
treat  all  suspicious  cases  as  he  would  those  of  actual  fracture,  and  the 
practice  is  the  only  safe  one  to  follow  now. 

In  the  absence  of  the  X-ray  as  an  aid  to  diagnosis,  or  in  cases  in 
which  the  plate  may  show  an  obscure  finding,  there  are  signs  which 
the  surgeon  should  look  for.  Langenbeck  laid  stress  on  swelling  of 
the  capsule  with  blood  which  is  most  apparent  on  the  front  of  the 
thigh  just  below  Poupart's  ligament.  The  pressure  of  the  tumor  back 
of  the  large  vessels  causes  the  femoral  artery  to  pulsate  perceptibly 
under  the  skin  of  the  groin.  Again  in  through-and-through  shots 
the  exact  location  of  the  "dangerous  region"  in  hip  cases  as  laid  down 
by  Lagenbeck  must  be  carefully  mapped  out.  According  to  him  the 
"dangerous  region"  is  included  in  "a  triangle  whose  base  intersects 
the  trochanter  major,  while  the  femur  and  the  anterior  superior  spine 
of  the  ilium  form  the  points  of  an  acute  angle."  Stevenson  suggests 
a  dangerous  space  included  in  "a  triangle  the  angles  of  which  are  at 
the  spine  of  the  pubes,  the  anterior  inferior  spine  of  the  ilium  and  the 
outermost  point  of  the  great  trochanter.  The  value  of  any  space, 
defined  by  invariable  lines,  is  necessarily  faulty.  This  was  true  in  the 
days  of  the  old  armament,  and  it  becomes  more  so  with  the  use  of 
present-day  rifle  bullets.  The  joint  capsule  may  be  penetrated  by 
reduced-caliber  bullets  antero-posteriorly  or  vice  versa  time  and  again 
without  implicating  the  osseous  structures  by  passing  above  or  below 
the  neck  of  the  femur. 

Treatment  of  Gunshot  of  the  Hip. — The  management  of  wounds 
of  the  hip  will  be  considered  under  the  following  heads:  (1)  Expec- 
tancy, (2)  Conservation,  (3)  Excision,  (4)  Amputation. 

Expectant  Treatment. — This  plan  contemplates  no  exploratory  or 


314  GUNSHOT   WOUNDS 

operative  interference.  Immobilization  and  a  clean  dressing  to  a 
clean  field  are  the  only  requirements  of  treatment.  This  plan  is  ap- 
plicable in  doubtful  injuries  to  the  joint,  in  which  the  external  wounds 
and  the  course  of  the  intervening  track  are  the  only  evidence  Avhich 
tends  to  lend  a  suspicion  of  joint  lesion.  In  such  cases,  with  the  use 
of  the  present  armament,  there  may  be  wound  of  the  capsule  only,  or 
slight  injury  to  bone,  such  as  grooving  or  a  clean-cut  perforation. 
In  such  cases  immobilization  and  a  clean  dressing  have  given  uni- 
formly good  results  in  the  Spanish-American  and  Boer  Wars. 

Conservative  Treatment. — -This  plan  of  treatment  is  to  be  pursued 
after  a  positive  diagnosis  of  gunshot  fracture  of  the  hip-joint  has  been 
made.  The  surgical  means  to  be  employed  are:  (1)  exploration  of 
the  joint;  removal  of  bone  fragments  or  missiles;  (3)  immobilization. 

In  cases  requiring  the  measures  which  aim  at  conservation  there 
will  usually  be  the  signs  of  fracture  such  as  shortening  of  the  limb, 
eversion  of  the  foot,  disturbed  relations  of  the  bony  points  about  the 
joint,  escape  of  synovia  or  lodged  ball.  In  addition  there  will  be  evi- 
dence of  the  character  of  the  lesion  from  the  knowledge  of  the  cahber 
of  the  projectile  which  inflicted  the  injury  as  judged  by  the  external 
wounds,  and  also  from  the  velocity  of  the  projectile  or  distance  at  which 
the  injury  was  received.  Injuries  to  the  bones  of  the  hip-joint  by 
shell  fragments  when  not  too  large;  lead  bullets  of  the  larger  calibers 
from  rifles,  revolvers  and  shrapnel;  as  well  as  steel-clad  bullets  from 
pistols  and  mihtary  rifles  at  proximal  ranges  usually  cause  fragmen- 
tation that  requires  surgical  interference. 

Exploration,  when  two  wounds  are  present,  can  usually  be  practised 
through  the  wound  of  exit.  This  should  be  enlarged  to  admit  the 
finger  when  necessary.  Missiles  or  small  loose  fragments  of  bone  that 
can  be  readily  removed  should  be  extracted  with  the  aid  of  the  finger 
and  forceps.  Larger  fragments  that  he  absolutely  loose,  free  from  bony, 
periosteal  or  soft  parts,  will  necessitate  enlargement  of  the  wound  and 
for  this  purpose  the  posterior  incision  employed  for  excisions  should 
be  done.  The  joint  and  wound  should  next  be  irrigated  and  drainage 
at  a  dependent  point  should  be  provided  for. 

Immobihzation  is  the  next  and  last  of  the  measures  in  the  scheme  of 
conservation.  Fixation  of  a  limb  is  easy  enough  in  a  stationary  hospi- 
tal, but  in  active  campaign  where  the  military  surgeon  encounters 
the  majority  of  his  cases  it  becomes  a  vexatious  problem — one  that 
will  often  tax  the  ingenuity  of  the  surgeon  to  the  utmost.  During 
enforced  transport  immobilization  is  next  to  impossible. 


GUNSHOT   WOUNDS    OF   JOINTS  315 

The  method  of  fixation  must  include  the  whole  limb  and  pelvis, 
and  the  wounds  should  remain  uncovered  by  the  fixation  apparatus, 
with  ready  access  for  redressing. 

Plaster  of  Paris  is  the  most  desirable  method  of  fixation  as  it  insures 
immobilization  and,  when  properly  applied,  extension  and  counter- 
extension  at  the  same  time.  Nothing  can  take  its  place  in  any  and 
all  kinds  of  transports.  Unfortunately,  it  is  not  always  adapted  to 
the  emergent  conditions  of  field  service  on  account  of  the  time  which 
is  required  to  apply  a  suitable  splint.  Surgeons  should  be  thoroughly 
familiar  with  the  method  of  applying  plaster  of  Paris  for  use  in  hip 
cases,  because,  unless  the  splint  is  properly  fitted,  it  does  more  harm 
than  good. 

Fixation  of  whatever  kind  should  be  practised  at  once,  from  the 
time  a  man  is  wounded  on  the  field.  In  the  absence  of  any  better 
method,  Delorme  and  other  surgeons  advise  bandaging  the  injured 
limb  to  the  sound  one  after  placing  sufficient  padding  between  the 
two  members  in  order  to  avoid  discomfort  and  to  secure  proper 
position. 

Wire  gauze  splinting,  extension  and  counter-extension  when 
practicable,  or  any  of  the  methods  used  in  field  practice  or  stationary 
hospitals  to  immobilize  limbs  may  be  employed  provided  immobiliza- 
tion is  complete  and  well  maintained. 

The  presence  of  suppuration  in  and  about  the  hip-joint  should  be 
treated  by  free  drainage  and  frequent  irrigation  with  antiseptic  solu- 
tions like  mercury  bichloride  1-4000.  Such  cases  usually  get  well 
with  more  or  less  anchylosis,  but  when  the  suppuration  continues 
excision  will  be  in  order  at  a  later  period,  when  the  active  inflammatory 
process  has  subsided.  Ample  nourishment  and  administration  of 
stimulants  should  be  given  in  the  meantime,  to  build  up  the  strength 
of  the  patient,  and  to  prepare  him  for  such  subsequent  measures  of 
surgical  relief  as  may  be  deemed  necessary. 

As  we  have  already  stated  in  the  beginning  of  this  chapter  the 
results  in  future  wars  will  be  very  encouraging  for  all  the  plans  of 
treatment  and  especially  for  those  after  conservative  treatment. 

Excision  of  the  Hip. — ^Hitherto  the  results  of  this  operative 
measure  have  been  alike  deplorable  in  civil  practice  and  active  cam- 
paign. We  cite  below  the  mortality  recorded  by  Otis  for  the  different 
periods  in  the  clinical  history  of  such  cases  before  the  days  of 
antisepsis. 


316  GUNSHOT   WOUNDS 

NUMERICAL   STATEMENT   OF  SIXTY-SIX   CASES  OF  EXCISION  AT 
THE  HIP-JOINT  FOR  SHOT  INJURY  DURING  OUR  CIVIL  WAR 


Operations 


Recovery 


Fatal 


Total 


Per  cent. 

of 
mortality 


Primary  operations 1  ,  32  '.         33  .       96 . 9 

Intermediary  operations 2  |         20         ''         22  ]       90 . 9 

72.7 


Secondary  operations. .  .-■: 

3 

8 

11 

Aggregates 

6 

60 

66 

90.9 


Otis  again  collected  the  statistics  of  161  cases  of  excision  and  the 
mortality  among  these  was  as  follows: 

Primary  operation 93      per  cent. 

Intermediate  operation 96 . 6  per  cent. 

Secondary  operation 63 . 4  per  cent. 

The  statistics  of  Gurlt  and  Langenbeck  collected  in  the  German 
wars  of  about  the  same  period  give  results  only  a  trifle  better. 

Notwithstanding  the  high  mortality  observed  by  Otis,  this  author 
bDldly  advocated  primary  excision  in  all  uncomplicated  cases  of  shot 
fracture  of  the  head  or  neck  of  the  femur.  He  wrote  at  a  time  when 
expectant  and  conservative  methods  of  treatment  were  invariably 
followed  by  sepsis  and  death,  or  complications  that  ended  in  prolonged 
suffering.  Under  our  present  methods  of  treatment  we  no  longer 
advocate  primary  excision  for  uncomplicated  fracture  of  the  head 
or  neck  of  the  femur.  It  has  been  almost  entirely  supplanted  by 
conservative  methods.  Out  of  three  cases  in  the  Spanish-American 
War,i  and  eight  in  the  Anglo-Boer  war  (Stevenson)  so  treated,  there 
were  three  deaths — a  mortality  of  27.2  per  cent.  Although  this 
number  is  small  to  predict  the  outcome  in  other  wars  we  confidently 
believe  that  it  will  serve  as  an  index  of  the  official  reports  of  the 
Manchurian  and  Turko-Balkan  campaigns,  when  these  are  published. 

Intermediate  Excision. — The  mortality  is  rated  so  high  when  the 
operation  is  performed  at  this  stage  in  the  clinical  history  of  such 
cases  that  it  should  be  seldom  resorted  to.     It  may  be  contemplated 

1  Report  S.  G.  O.,  U.  S.  A.,  1899-1901. 


GUNSHOT    WOUNDS    OF   JOINTS  317 

in  cases  which  might  have  suffered  excision  primarily,  when  the  latter 
was  delayed  for  insufficient  diagnosis,  or  proper  opportunity  to  control 
one's  surroundings;  but  in  such  cases  it  will  always  be  wiser  to  adopt 
conservative  measures  such  as  the  removal  of  loose  fragments  of  bone, 
free  irrigation,  drainage,  and  the  careful  use  of  antiseptic  materials.  In 
this  way  one  will  often  succeed  in  arresting  an  active  inflammatory 
process  or  in  tiding  the  case  over  to  a  suitable  time  for  a  secondary 
excision. 

Secondary  excision  is  practised  when  efforts  at  conservation  fail 
through  the  introduction  of  sepsis  into  the  wound,  and  when  all 
efforts  to  stay  the  inflammatory  process  have  been  unavailing.  In 
such  cases  necrosis  of  bone  is  common,  fragments  primarily  attached 
have  become  loose,  and  the  case  requires  thorough  exploration  and 
excision  to  remove  all  diseased  tissues  properly. 

There  were  but  eleven  secondary  excisions  recorded  in  our  Civil 
War  by  Otis,  with  a  mortality  rate  of  72.7  per  cent.  The  number 
of  cases  for  this  great  war  is  small,  but  it  is  accounted  for  b}^  the  fact 
that  comparatively  few  patients  survived  injuries  involving  the  hip- 
joint  until  the  time  for  secondary  excision  had  arrived. 

Otis  observes  (1883)  that  since  the  Civil  War  the  operation  of  exci- 
sion of  the  hip  for  shot  injury  has  been  practised  five  times  in  the 
U.  S.  Army  and  once  in  the  U.  S.  Navy  and  this  aggregate  of  six  cases 
gives  four  recoveries.  We  took  one  of  these  army  cases  off  the  field 
during  an  Indian  campaign  in  Wyoming  in  1876  along  with  a  number 
of  others  seriously  wounded.  The  following  is  an  abstract  from  the 
history^  of  the  case :  Sergeant  William  J.  Linn,  Co.  M,  4th  Calvary,  was 
shot  Nov.  26,  1876,  with  a  50-caliber  conoidal  bullet  weighing  412 
grains  in  a  battle  with  Indians.  The  ball  passed  through  the  right 
hip-joint  while  he  was  resting  on  his  right  knee  and  left  foot  in  the  act 
of  firing  his  carbine.  A  plaster-of-Paris  bandage  was  applied  to  the 
injured  limb  at  once,  including  a  spica  around  the  waist,  and  the  next 
day  he  was  moved  on  a  travois  through  a  mountain  region  without 
roads,  in  excessively  cold  weather.  We  reached  our  base  of  supplies 
on  the  third  day.  The  plaster-of-Paris  cast  was  here  removed,  and 
after  establishing  free  posterior  drainage  a  new  plaster-of-Paris  cast 
was  securely  applied  as  before  and  the  patient  was  carried  by  ambu- 
lance five  days  over  a  country  devoid  of  roads,  in  what  was  then  known 
as  the  most  inhospitable  region  of  our  country,  in  cold  weather  that 
hovered   around   zero   most   of   the  time.     Lieutenant  John  Van  R. 

1  Med.  and  Surg.  History  War  Rebellion,  Surg.  Vol.,  Part  III,  p.  123. 


318  GUNSHOT   WOUNDS 

Hoff,  Medical  Corps,  now  Colonel  U.  S.  Army,  retired,  who  reported 
the  case  successfully  performed  secondary  excision  of  the  hip-joint 
ten  months  later.  He  found  the  head  of  the  femur  loose  in  the  joint 
cavity.  It  had  been  severed  from  the  neck  by  the  bullet  and  this  with 
other  necrosed  bone  including  the  upper  end  of  femur  just  below  the 
great  trochanter,  were  entirely  removed.  Two  years  later  this 
soldier  had  so  far  recovered  the  use  of  his  limb  that  he  got  along  with- 
out a  crutch,  and  only  used  a  walking  cane  on  long  walks. 

We  believe  this  case  was  tided  over  the  active  inflammatory 
period  during  transport  because  of  good  drainage  and  thorough  im- 
mobilization with  plaster  of  Paris.  Our  attempts  at  antisepsis  in  that 
time  were  very  crude,  and  under  the  conditions  then  prevailing  sepsis 
was  unavoidable. 

The  best  method  of  performing  excision  of  the  hip  need  not  occupy 
us  here.  Generally  speaking  the  posterior  incision  extending  from  a 
half-inch  below  the  anterior  superior  spine  of  the  ilium  and  passing 
downward  over  the  most  prominent  part  of  the  great  trochanter  will 
afford  better  drainage  and  in  cases  in  which  the  greater  trochanter  is 
implicated  the  opportunity  to  observe  the  extent  of  lesion  and  remove 
loose  fragments  makes  this  incision  particularly  advantageous. 

The  after-treatment  is  the  same  as  that  for  chronic  hip-joint  cases 
generally. 

Amputation  of  the  Hip -joint. — The  results  of  all  amputations  at 
the  hip-joint  in  military  practice  were  collected  by  Otis,  including  the 
sixty-six  cases  which  occurred  in  our  Civil  War.  The  mortality  is 
thus  referred  to  by  the  great  author — ''we  thus  arrive  at  an  aggregate 
of  250  cases  of  exarticulation  at  the  hip  as  the  present  status  of  this 
grave  mutilation  in  military  surgery,  with  twenty-seven  recoveries, 
222  deaths,  and  one  example  with  unknown  result  or  a  mortality  of 
89.1  per  cent."  Of  twenty-five  primary  amputations  among  the 
sixty-six  cases  in  the  Civil  War  death  occurred  in  twenty-two  cases,  a 
mortahty  of  88  per  cent.  The  operation  in  the  intermediate  stage 
in  twenty-three  cases  gave  the  usually  high  mortality — 100  per  cent., 
and  77.7  per  cent,  in  nine  cases  in  the  secondary  stage.  In  thirteen 
of  the  twenty-two  fatal  cases  in  the  first  group  the  wounds  were  in- 
flicted by  cannon  shot,  shell  fragments  or  other  large  projectiles 
causing  in  all  instances  extensive  mutilation,  and  noted  in  words  hke 
the  following:  shattering  of  the  femur  high  up  and  mangling  of  soft 
parts,  tearing  away  of  muscles  and  comminuting  the  neck  and  tro- 
chanters, inflicting  terrible  laceration  of  the  upper  and  exterior  part  of 


GUNSHOT    WOUNDS    OF   JOINTS  319 

the  thigh,  comminuting  the  upper  third  of  the  femur  and  fracturing 
the  tuberosity  of  the  ischium,  etc.,  etc.  In  six  instances  it  was 
necessary  to  perform  primary  disarticulation  at  the  hip  because  of 
graver  injuries  to  the  femur  conjoined  with  lesions  of  the  femoral 
artery.  Of  the  three  who  recovered  the  first  was  struo*^  by  a  frag- 
ment of  a  24-pounder  shell  crushing  the  trochanters  and  neck  of  femur 
and  wounding  the  femoral  artery,  the  second  received  a  conoidal  ball 
fracture  of  the  right  femur,  fissures  extending  into  neck  quite  within 
capsular  ligament,  and  the  third  suffered  comminution  from  a  round 
ball  and  buck,  comminuting  the  femur  just  below  trochanters. 

It  is  interesting  to  note  that  of  nine  reamputations  at  the  hip-joint 
for  osteomyelitis  and  other  secondary  complications  there  were  but 
three  deaths — a  mortality  of  33.3  per  cent.  The  reamputations  were 
rendered  necessary  in  cases  which  had  suffered  amputation  in  the 
middle  and  lower  third  of  the  thigh. 

In  three  secondary  disarticulations  in  the  Spanish-American  War 
there  was  one  death  and  in  the  Anglo-Boer  War  Stevenson  reports 
thirteen  cases  with  eight  deaths,  making  an  aggregate  mortality  of 
56.2  per  cent,  for  the  sixteen  cases  in  these  two  wars. 

Shock  and  hemorrhage  cause  the  great  mortality  in  primary  ampu- 
tation of  the  hip-joint.  The  environments  in  active  campaign  rather 
forbid  the  risk  attendant  upon  such  a  marked  capital  operation.  The 
rule  of  the  present  is  to  postpone  all  cases,  when  possible,  to  the  secon- 
dary stage  and  at  a  time  when  the  environments  are  more  propitious. 

In  those  cases  of  injury  by  shell  fragments  which  are  apt  to  destroy 
the  limb,  Langenbeck  recommended  removal  of  the  head  of  the  former 
primarily,  leaving  amputation  of  the  limb  to  be  practised  later.  In 
this  way  the  extreme  additional  shock  of  amputation  is  avoided.  With 
the  resources  of  modern  surgery  at  hand,  except  in  very  extensive 
injuries  of  the  soft  parts,  the  management  of  the  cases  should  be 
directed  toward  saving  the  limb,  and  should  this  prove  unavailing 
secondary  amputation  can  be  practised  later  with  far  less  danger  to 
life. 

Wounds  of  the  hip-joint  in  recent  wars  are  necessarily  few  in 
number.  We  await  the  official  reports  from  the  Manchurian  and 
Turko-Balkan  campaigns  with  confident  hope  of  renewed  achievements 
for  modern  surgical  practice. 

Gunshot  Wounds  of  the  Knee-joint. — With  the  use  of  the  old 
armament  wounds  of  the  knee-joint  numbered  28.7  per  cent,  of  all 
joint  wounds  in  military  practice  and  3  per  cent,  of  all  war  wounds. 


320  GUNSHOT   WOUNDS 

The  frequency  of  gunshot  of  this  joint  is  now  less  than  formerly  be- 
cause of  modern  tactics  which  require  men  to  fight  under  cover.  Out 
of  4756  gunshot  wounds  of  all  parts  tabulated  by  the  Surgeon-GeneraP 
in  the  Spanish- American  War,  injuries  to  the  knee-joint  constituted 
about  23  per  cent,  of  all  joint  wounds,  and  1/2  per  cent,  of  wounds 
of  all  parts. 

For  purposes  of  study  gunshot  wounds  of  the  knee-joint  are 
divided  into:  (a)  simple  perforation  of  the  synovial  sac  without  ac- 
companying lesion  of  any  bone;  (b)  injury  to  the  joint  with  lodged 
ball;  (c)  injury  to  the  joint  exhibiting  guttering  of  the  articular  ends 
of  the  bones;  (d)  complete  perforation  of  the  articuler  ends  of  bones 
in  different  directions;  (e)  implication  of  the  joint  by  fissuring  and 
comminution  of  the  bones  entering  into  its  formation. 

(a)  Simple  perforation  of  the  synovial  sac  is  known  to  be  of  more 
frequent  occurrence  now  than  formerly.  During  the  days  of  larger 
calibers  it  was  necessarily  infrequent,  but  so  late  as  the  Civil  War, 
under  the  designation  of  peri-articular  wounds,  Otis  collected  351 
cases  with  a  mortality  of  29.9  per  cent.  Of  the  351  cases,  he  estimates 
that  255  cases  suffered  direct  involvement  of  the  capsule  without 
fracture  ''and  that  in  ninety-six  cases  the  projectiles  did  not  injure 
the  joint,  which  was  opened  by  secondary  traumatic  arthritis." 
Considering  the  difficulties  of  diagnosis  which  prevailed  at  that  time 
and  the  fact  that  many  of  those  who  got  well  were  not  actually  verified 
as  simple  synovial  perforations,  it  may  be  admitted  with  propriety 
that  some  of  Otis'  cases  were  complicated  by  at  least  slight  osseous 
lesions.  Nevertheless  it  has  been  definitely  ascertained  by  actual  ex- 
perience and  by  experiment  that  a  bullet  can  traverse  the  joint,  when 
the  leg  is  in  any  position  except  complete  extension  by  entering  below 
the  patella  and  ranging  antero-posteriorly.  It  thus  finds  sufficient 
room  to  pass  through  the  intercondyloid  notch  without  inflicting  frac- 
ture of  the  articular  ends.  There  is  sufficient  space  from  side  to  side 
under  the  extensor  muscles  for  a  ball  of  moderate  diameter  to  penetrate 
the  reflection  of  the  synovial  membrane  in  that  region.  Again,  when 
the  knee  is  slightly  flexed,  the  tibia  and  condyles  are  widely  separated 
and  there  is  ample  space  for  a  bullet  to  traverse  the  synovial  sac  in 
the  anterior  third  of  the  joint  behind  the  patella.  Examples  such  as 
those  mentioned  were  noted  with  the  larger  calibers  by  military  sur- 
geons in  all  wars  and  they  will  be  far  more  frequent  with  the  use  of 
reduced  calibers  henceforth.     Peri-articular  wounds  with  involvement 

1  Reports  of  S.  G.,  U.  S.  Army,  for  1898-99. 


GUNSHOT   WOUNDS    OF   JOINTS 


321 


of  the  synovial  membrane  will  be  as  frequent  as  formerly.  Stevenson 
states  that  wounds  of  the  synovial  membrane  alone  were  fairly  common 
in  the  Boer  War. 

(b)  Injury  to  the  Joint  with  Lodged  Ball, — Projectiles  have  been 
known  to  lodge  in  the  joint  cavity  without  implicating  bony  structures. 
Balls  lodge  in  or  about  the  knee-joint  more  often  than  in  any  of  the 


Fig.  135. — Radiogram  showing  postero-anterior  and  lateral  views  of  knee  in  case  of  Pvt. 
William  R.  Barret,  29th  Co.,  U.  S.  Coast  Artillery.  Exposure  was  made  in  1909.  This  man  was 
shot  prior  to  enlistment  with  a  .38  cal.  Smith  and  Wesson  revolver  and  the  presence  of  the  missile 
in  the  knee  was  not  detected  until  he  had  been  in  the  service  some  time.  The  washers  were  used  as 
localizers.     Army    Medical   School   collection. 


articulations.  They  are  at  times  found  in  the  joint  but  more  often 
they  are  located  in  the  epiphyseal  ends  of  the  tibia  or  femur.  (Fig. 
135.)  Lodged  balls  in  or  about  the  knee  formerly  proved  a  ser- 
ious complication  in  gunshot  of  this  articulation  (Fig.  136).  Much 
harm  was  done  in  attempts  to  explore  for  the  missile,  and  the  search 
was  more  often  futile.     Under  our  present  methods  of  diagnosis  with 


322  GUNSHOT   WOUNDS 

the  aid  of  the  X-ray,  knee  cases  complicated  by  lodged  balls  are 
promptly  relieved.  Out  of  ninety-five  gunshot  of  the  knee  in  the 
Anglo-Boer  War  lodged  bullets  were  removed  from  ten  cases  (Spencer), 
(c)  Injury  to  the  joint  exhibiting  guttering  of  bone  is  one  of  the 
frequent  lesions  about  the  articular  ends  of  the  femur  and  tibia  with 
the  use  of  reduced  calibers.  The  lesion  may  be  superficially  disposed 
about  the  contour  of  the  joint  ends,  or  there  may  be  a  superficial 


Fig.  136. — Pvt.  Roman  Carinom,  Co.  18th  Philippine  Scouts,  wounded  by  what  was  thought 
to  be  a  reduced  caliber  rifle  bullet  in  engagement  with  Moros  in  1912.  Missile  which  appeared  to  be 
part  of  the  core  of  an  armored  bullet  was  removed  by  opening  joint.  It  was  imbedded  in  articu- 
lating surface  of  outer  condyle.  Army  Med.  School  collection.  X-ray  Laboratory,  Division  Hos- 
pital,   ^Manila,    P.    I. 

grooving  of  the  joint  surfaces  proper,  with  spicules  of  bone  protruchng. 
The  amount  of  lesion  in  any  wound  exhibiting  grooving  will  necessarily 
be  proportional  to  the  sectional  area  of  the  bullet.  Grooving  by  the 
modern  bullet  is  clean-cut  except  in  shots  delivered  at  the  proximal 
ranges.  Here  there  may  be  short  fissures  radiating  from  the  track 
of  the  bullet  with  detached  particles  of  bone  in  the  joint  or  in  adjacent 
tissues. 

(d)  Complete  perforation  traversing  the  joint  in  different  direc- 
tions were  occasionally  noted  in  the  days  of  the  older  calibers,  but  they 


GUNSHOT   WOUNDS    OF   JOINTS  323 

have  become  especially  common  since  the  adoption  of  steel-jacketed 
rifle  bullets,  and  they  are  typically  shown  in  the  bony  structures  of 
the  knee.  In  the  mid  ranges  clean-cut  perforations  are  the  rule  through 
the  patella,  condyles  of  the  femur  and  the  epiphyseal  end  of  the 
tibia.  Proximal  shots  from  the  new  military  rifle  which  perforate  near 
the  joint  surfaces  may  exhibit  fissures  opening  on  the  joint  surfaces, 
but  when  present  they  are  more  apt  to  be  subperiosteal  in  nature. 
As  already  stated  perpendicular  shots,  which  cross  the  joint  by  the 
shortest  route  inflict  a  minimum  amount  of  injur}'-  and  are  attended 
with  the  best  results. 

(e)  Implication  of  the  joint  by  Assuring  and  comminution  of  the 
bones  entering  into  its  formation  was  the  common  lesion  inflicted  by 
shell  fragments  and  the  old  lead  rifle  bullets  of  former  times.  In 
modern  wars  they  are  still  observed  as  a  result  of  shell  fragments  and 
shrapnel  balls.  The  amount  of  lesion  is  always  proportional  to  the 
sectional  area  and  velocity  of  the  projectile  on  impact.  A  shot  from  the 
larger  calibers  at  proximal  ranges  which  strikes  the  lower  end  of  the 
femur  just  above  the  intercondyloid  notch  is  apt  to  detach  the  condjdes 
from  the  shaft  as  a  result  of  deep  fissures  extending  upward.  The  di- 
aphysis  of  the  tibia  just  before  it  unites  with  the  upper  epiphysis  is 
made  up  of  hard  compact  bone,  so  that  shots  at  high  velocity  and 
sufficient  sectional  area  near  the  epiphyseal  junction  will  at  times  com- 
minute the  epiphysis  into  the  joint,  producing  isolated  fragments  of 
varjdng  sizes.  The  tendencj^,  however,  vnth.  armored  bullets  of 
reduced  calibers  is  to  make  perforations  in  the  epiphyseal  ends  of 
bones,  and  this  tendency  is  still  observed  in  the  diaphj^sis  adjacent 
to  the  knee-joint  whether  the  bullet  traverses  the  upper  end  of  the  tibia 
or  lower  end  of  the  femur. 

Diagnosis. — -The  diagnosis  of  wound  of  the  joint  will  rest  largely 
upon  a  study  of  the  location  of  the  apertures  of  entrance  and  exit. 
Effusion  of  blood  into  the  joint,  swelling,  pain  and  inability  to  move  the 
knee,  are  all  valuable  signs.  Fracture  will  be  attended  by  crepitation. 
Displacement  of  bony  fragments  when  present  is  an  absolute  sign. 
The  amount  and  kind  of  lesion  and  the  presence  of  lodged  missiles 
will  have  to  rest  on  X-ray  evidence. 

Treatment. — The  treatment  employed  in  preantiseptic  times  was 
(1)  amputation,  (2)  conservation,  and  (3)  excision.  Among  these 
methods  amputation  was  the  rule  adopted  in  our  great  Civil  War,  and 
the  surgeon  who  adopted  any  other  course  in  any  gunshot  wound  of  the 
knee  was  considered  to  be  remiss  in  his  duty  to  his  patient.     Conserva- 


324  GUNSHOT   WOUNDS 

tion  and  excision  were  only  practised  in  those  cases  where  the  patient 
refused  amputation.  The  limb  was  sacrificed  even  in  those  cases  where 
the  joint  capsule  alone  was  supposed  to  be  injured.  In  313  cases  of 
this  kind  treated  without  operation  the  mortality  was  22  per  cent. 
(Otis). 

When  antisepsis  was  first  adopted  our  earliest  observations  of  its 
value  in  military  field  practice  were  brought  forth  by  Reyher  and  Von 
Bergmann  in  the  Russo-Turkish  War  of  1877-78.  Reyher  reported  \ 
eighteen  primary  aseptic  cases  of  wounds  of  the  knee,  regardless  of  the 
extent  of  joint  involvement,  dressed  antiseptically,  of  whom  three 
died,  a  mortality  of  16.6  per  cent.  The  treatment  was  entirely  con- 
servative. He  employed  weak  carbolic-acid  irrigations  in  severe 
cases  while  the  simple  cases  were  cleansed  and  dressed  with  wet  carbolic 
gauze.     Those  who  got  well  recovered  with  movable  joints. 

Von  Bergmann  used  the  same  antiseptic  details  in  fifteen  cases 
of  gunshot  fracture  of  the  knee  with  fourteen  recoveries,  two  of  the 
successful  cases  having  suffered  amputation.  The  only  fatal  case 
was  one  in  which  amputation  was  practised.  Although  no  reference  is 
made  as  to  the  utility  of  the  limbs  in  the  non-amputated  cases,  it  is 
presumed  that  they  got  well  with  movable  joints.  Since  the  ex- 
perience of  Reyher  and  Von  Bergmann  was  obtained  prior  to  the 
introduction  of  the  new  military  rifle,  their  cases  must  represent 
injuries  by  the  old  leaden  conoidal  bullet  of  about  forty-five  calibers, 
weighing  approximately  480  grains,  and  having  an  initial  velocity  of 
about  1300  f.s. 

Gouped  together  we  find  that  the  cases  of  Reyher  and  Von 
Bergmann  which  suffered  lesion  from  similar  weapons  and  which  were 
treated  antiseptically  have  an  aggregate  mortality  of  11.1  per  cent. 

The  statistics  recorded  by  Otis  show  that  in  868  gunshot  fractures 
of  the  knee  in  the  Civil  War  treated  by  conservation  there  was  a 
mortality  of  60.6  per  cent.  Amputation  as  a  mode  of  treatment  was 
practised  in  2431  cases.  When  amputation  was  performed  through  the 
joint  the  mortality  was  56.6  per  cent,  and  when  it  was  done  through 
the  lower  third  of  the  femur  the  mortality  was  53.6  per  cent. 

Compared  to  the  results  obtained  in  the  Civil  War  in  preantiseptic 
times  after  lesions  of  the  old  armament,  the  results  of  Reyher  and 
Von  Bergmann  with  practically  the  same  kind  of  wounds,  aided  by  the 
use  of  antiseptics,  stand  out  as  a  great  triumph  in  favor  of  modern 
methods. 

The  cases  treated  in  the  Spanish-American  War  and  Philippine 


GUNSHOT   WOUNDS    OF   JOINTS  325 

Insurrection  from  1898  to  1902  numbered  seventy-seven  all  told  with 
six  deaths,  one  of  the  deaths  was  due  to  tetanus.  If  this  is  excluded 
from  the  list  it  gives  seventy-six  cases  with  five  deaths — a  mortality 
of  6.0  per  cent.  These  wounds  were  due  to  all  kinds  of  fire-arms  in- 
cluding large-  and  small-caliber  hand  weapons,  shell  fragments,  and 
shrapnel. 

There  were  ninety-five  gunshots  of  the  knee-joint  in  the  Anglo- 
Boer  War  with  a  mortality  of  4.2  per  cent.  Amputation  was  performed 
in  11.5  per  cent,  of  the  cases,  all  of  which  were  injured  by  shell  frag- 
ments, and  according  to  Stevenson  the  fatalities  were  confined  to 
septic  cases  from  severe  shell  fractures.  We  can  surmise  from  this 
report  that  the  other  knee-joint  injuries  in  which  no  deaths  occurred 
resulted  from  hits  by  the  projectiles  of  hand  weapons,  mostly  reduced- 
caliber  Mausers.  This  evidence  agrees  with  our  experience  at  the 
battle  of  Santiago.  Out  of  seventeen  cases  of  gunshot  injury  by 
the  reduced-caliber  Spanish  Mauser  there  was  not  a  death,  fourteen 
of  the  men  hit  recovered  so  that  they  were  restored  to  duty,  and  three 
were  discharged  on  surgeon's  certificate  of  disability  or  otherwise 
disposed  of. 

The  results  after  gunshot  of  the  knee-joint  by  reduced-caliber  bul- 
lets, and  the  use  of  modern  methods  of  treatment  point  in  a  most 
striking  manner  to  the  beneficence  which  has  come  from  antisepsis 
and  the  humane  injuries  from  steel-jacketed  bullets  of  the  modern 
military  rifle. 

Conservation  in  the  wars  of  the  present  day  should  be  practised 
in  all  cases  in  which  the  lesion  of  the  knee  has  resulted  from  reduced- 
caliber  bullets.  This  rule  has  been  adopted  as  a  result  of  observation 
of  the  nature  of  the  lesions  inflicted  in  war,  and  in  the  experimental 
field  as  well.  The  humane  character  of  joint  wounds,  especially  those 
of  the  knee,  was  foretold  long  before  any  war  was  fought  with  the  new 
armament,  and  the  work  of  the  experimenters,  which  was  so  unjustly 
assailed  by  cities  here  and  there,  is  no  where  more  significantly  brought 
out  than  we  find  it  in  the  knee-joint.^ 

In  the  more  simple  cases  no  attempts  at  exploration  should  be  made 
except  for  pieces  of  clothing  or  foreign  bodies.  Wounds  of  the  patella 
alone  are  generally  in  the  nature  of  a  perforation  and  when  fragmented 
the  fragments  are  usually  well  held  together  by  ligamentous  tissue  so 
that  no  surgical  operation  is  required.  In  so  far  as  the  patella  alone 
is  concerned,  the  treatment  is  the  same  as  practiced  in  shots  which  in- 
1  Report  S.  G.,  U.  S.  A.,  for  1893. 


326  GUNSHOT   WOUNDS 

elude  the  sjaiovial  membrane  or  the  osseous  tissues  of  the  joint  proper. 

When  spHntering  and  fragmentation  of  the  ends  of  the  tibia  and 
femur  are  marked  as  shown  by  palpation  it  may  become  necessary  to 
explore  the  joint  for  the  removal  of  loose  pieces  of  bone.  This  should 
be  done  by  laying  open  the  joint  or  by  enlarging  the  wound  of  exit. 
If  it  is  necessary  to  obtain  sufficient  room  for  purposes  of  diagnosis, 
an  incision  may  be  made  on  one  or  the  other  side  of  the  patella,  or  a 
horse-shoe  flap,  convexity  downward,  should  be  raised,  as  recommended 
in  formal  excision  of  the  knee.  After  dividing  the  ligamentum 
patellae,  the  lateral  and  crucial  ligaments,  ample  room  will  be  found 
both  for  purposes  of  diagnosis  and  such  operative  interference  as  may 
be  deemed  necessary.  After  removing  loose  pieces  of  bone,  lodged 
missiles,  or  other  extraneous  matter,  the  synovial  sac  and  wounded 
surfaces  should  be  irrigated  with  a  weak  antiseptic  solution,  the 
incised  surfaces  should  next  be  brought  together  with  appropriate 
sutures,  and  the  necessary  drainage  provided  for.  The  latter  should 
remain  in  place  from  thirty-six  to  forty-eight  hours.  The  limb  should 
next  be  dressed  and  immoblilized  upon  a  fenestrated  wire  or  plaster-of- 
Paris  splint. 

If  suppuration  supervenes  prompt  incision  and  ample  drainage  will 
be  required.  If  the  case  becomes  septic,  and  shows  no  signs  of 
improvement  the  surgeon  will  have  to  be  guided  largely  by  the  eviron- 
ments  at  hand.  Where  persistent  and  watchful  care  cannot  be  main- 
tained as  in  enforced  transport,  the  patient's  chances  will  be  better, 
if  amputation  is  resorted  to  in  the  lower  third  of  the  thigh. 

Anchylosis  more  or  less  complete  is  the  rule  in  knee  cases  that 
recover  after  extensive  comminution,  or  in  cases  complicated  by 
suppuration. 

Primary  excision  of  the  knee  has  never  been  a  favorite  operation 
in  military  practice.  Otis,  MacCormac  and  other  noted  surgeons  do 
not  recommend  it.  It  should  only  be  resorted  to  in  the  case  of  shell 
wounds  with  much  fragmentation,  in  patients  who  positively  refuse 
amputation.  The  old-time  death  rate  from  excision  of  the  knee  was 
largely  from  causes  which  are  at  present  partly  avoidable.  In  thirty- 
two  recorded  cases  by  Otis  in  our  Civil  War  the  mortality  was  86.6 
per  cent.  In  other  wars  in  the  preantiseptic  era  the  mortality  ranged 
as  high  as  90  per  cent.  We  have  no  statistics  to  show  the  results  of 
excision  under  modern  surgical  conditions,  but  we  have  reason  to  believe 
that  formal  primary  excision  of  the  knee  under  proper  environment 
may  yet  find  favor  in  military  practice. 


GUNSHOT    WOUXDS    OF   JOINTS  327 

Intermediate  and  Secondary  Excision. — ^The  fatalit}-  for  excision 
in  the  intermediate  stage  was  very  great  in  the  Civil  War,  only  one 
recovery  ha^dng  been  recorded  in  thirteen  cases.  The  operation  would 
doubtless  be  as  fatal  now  but  it  is  no  longer  recommended.  Secondary 
amputation  affords  a  far  better  chance  of  life.  Secondary  excisions 
find  no  more  favor  in  military  than  they  do  in  civil  practice.  The 
operation  was  done  in  two  instances  in  the  Spanish-American  War 
with  one  recovery. 

Primary  amputation  for  injury  to  the  knee-joint  is  onl}^  recom- 
mended in  cases  of  extreme  traumatism  of  the  bones,  soft  parts  and 
large  vessels.  Such  injuries  are  usually  sustained  by  shell  fragments, 
and  the  patients  more  often  die  of  shock  and  hemorrhage  before  reach- 
ing hospital  care.  The  limb  should  be  amputated  through  the  joint 
or  the  lower  third  of  the  femur  depending  upon  the  amount  and  condi- 
tion of  the  material  for  flaps.  Statistics  favor  amputation  at  the  latter 
point. 

Gunshot  Wounds  of  the  Ankle-joint. — Among  war  wounds  of  the 
foot  by  gunshot,  those  confined  to  the  ankle-joint  aggregate  one-third 
of  the  whole.  Like  most  of  the  wounds  of  joints,  gunshot  injuries  of  the 
ankle  are  divided  into  those  of  the  articulation  without  and  with 
bone  involvement.  The  former  were  designated  under  the  term  peri- 
articular wounds  by  Otis,  of  which  there  were  thirty-seven  cases  in 
the  Civil  War,  and  1711  of  those  with  bone  lesion.  The  peri-articular 
wounds,  as  designated  by  Otis,  included  injury  to  the  tissues  immedi- 
ately surrounding  the  joint,  like  the  vessels,  nerves,  tendons,  and  mal- 
leoli, mthout  involving  the  joint  cavity,  and  also  cases  in  which  the 
synovial  sac  of  the  joint  was  penetrated  -odthout  bone  lesion.  He 
does  not  state  how  many  of  the  thirty-seven  peri-articular  wounds  were 
of  the  latter  class.  We  have  demonstrated  experimentally  on  the 
cadaver  that  it  is  possible  for  a  reduced-caliber  bullet  to  penetrate 
the  synovial  sac  transversely  in  front  or  behind  on  a  line  ^^^th  the  ar- 
ticular surfaces  of  the  tibia  and  astragalus  ^\dthout  injuring  bony  parts. 
On  account  of  its  superficial  position,  wounds  of  the  synovial  membrane 
of  the  ankle  alone  are  generally  admitted  to  be  of  rare  occurrence, 
much  more  so  than  we  find  in  either  the  shoulder,  hip,  or  knee. 

Gunshot  Fracture  of  the  Bones  of  the  Ankle-joint. — The  sectional 
area  and  velocity-  of  the  projectile  will  have  great  influence  upon  the 
osseous  lesion  in  gunshot  of  the  ankle-joint.  The  proJGctiles  of  the 
days  of  the  Civil  War  inflicted  injury  that  was  more  often  marked 
by  comminution,   detached  fragments,   and  extensive  laceration  of 

22 


328  GUNSHOT    WOUNDS 

the  ligaments,  tendons,  etc.,  about  the  joint.  Wounds  of  the  astrag- 
alus by  reduced-cahber  bullets  generally  groove  its  superior,  inferior, 
and  lateral  surfaces  with  few  fissures,  the  latter  being  more  often  sub- 
periosteal or  sub-cartilaginous.  When  the  body  of  the  bone  is  hit 
the  lesion  is  marked  by  a  clean-cut  perforation  in  the  mid  ranges.  If 
the  projectile  is  animated  by  a  high  velocity,  the  perforation  will  be 
attended  with  fissures  extending  in  the  substance  of  the  bone,  and  when 
the  bullet  makes  an  impact  at  its  maximum  velocitj^  the  bone  may  be 
pulverized  into  minute  fragments,  the  wound  of  entrance  and  exit 
being  filled  with  bonj^  sand.  The  lower  end  of  the  fibula,  viz.,  the 
external  malleolus,  which  consists  of  epiphyseal  tissue,  may  be  grooved 
or  perforated  with  or  without  fissures  extending  into  the  joint.  The 
bone  opposite  the  joint  higher  up  is  very  hard  and  brittle.  Shots  at 
this  point  in  the  fibula  are  apt  to  show  considerable  comminution  in- 
volving the  joint  cavity.  Shot  injuries  located  in  the  joint  end  of  the 
tibia,  viz.,  in  the  epiphyseal  tissue  which  includes  the  lower  end  of  the 
internal  malleolus  and  about  13  inch  of  the  lower  end  of  the  bone 
proper,  are  prone  to  show  the  same  tendencj"  to  clean-cut  perforation 
that  one  observes  in  the  joint  ends  of  bones  generally,  but  lesions  in 
this  limited  area  are  not  often  seen.  The  bone  involvement  generally 
includes  the  tibia  above  the  epiphyseal  line  where  the  compact  bone 
is  hard  and  the  resulting  lesion  will  show  long  fissures  extending 
upward  and  downward  into  the  joint.  The  amount  of  comminution 
or  fragmentation  will  be  proportional  to  the  sectional  area  of  the  pro- 
jectile and  the  amount  of  energ}-  delivered  on  impact. 

Lesions  from  shrapnel  and  shell  fragments  will  generally  be  ex- 
treme in  character  and  those  from  the  latter  especially  will  require 
immediate  amputation  as  a  rule. 

The  treatment  of  gunshot  of  the  ankle  will  be  taken  up  under 
conservation,  excision  and  amputation. 

Conservation. — About  the  time  of  our  Civil  War  militarj^  surgeons 
generally  followed  the  teachings  of  Larrey,  Thompson,  Guthrie  and 
others  which  favored  amputation  almost  exclusive^  in  gunshot  of  the 
ankle.  The  wounds  of  those  days  showed  characteristics  that  favored 
the  development  of  sepsis,  and,  in  a  location  so  beset  with  dirt  as  the 
ankle,  the  dangers  of  the  virulent  infections  were  especially  marked. 
Guthrie,  in  his  treatise  on  Gunshot  Wounds,  states  that  "Wounds  of 
the  ankle-joint  from  gunshot  are  extremely  dangerous,  and  in  general 
require  amputation."  Thompson,  in  his  report  of  observations,  etc., 
after  the  battle  of  Waterloo,  states  that  "Wounds  in  which  musket 


GUNSHOT    WOUXDS    OF    JOINTS  329 

balls  have  passed  through  or  lodged  in  the  aiikle-joint  almost  all  require 
immediate  amputation.     These  injuries  by  giving  rise  to  high  degrees 

of  inflammation not  infrequent^  prove  fatal.     Among  a 

great  number  who  had  survived  the  fever  we  saw  but  few  in  whom 
secondary  amputation  was  not  required,  and  in  the  cases  requiring  it 
this  operation  was  far  from  being  so  successful  as  the  primary  ampu- 
tation had  been."  The  expressions  of  Larrey  are  all  to  the  same  effect. 
Our  surgeons  in  the  Civil  War  avoided  conservation  for  similar  reasons. 
In  1711  gunshot  fractures  of  the  ankle-joint  reported  by  Otis  but  518 
were  treated  by  this  method.  Generally  the  less  severe  cases  were 
selected  for  the  conservation  method  and  even  then  the  mortality  rate 
was  19.5  per  cent. 

Among  those  who  recovered  from  gunshot  injury  of  the  ankle  after 
conservation  in  the  preantiseptic  era  the  results  on  the  score  of  utility 
of  the  foot  and  limb  were  generallj^  bad.  The  foot  was  more  often 
ankylosed  in  the  tibio-astragalian  articulation  and  oftentimes,  of  more 
serious  import,  the  ankylosis  extended  to  the  astra-calcanian  articula- 
tion. There  were  deviations  of  the  foot  laterally  or  antero-posteriorly , 
the  loss  of  tendons,  necrosis,  and  long-continued  inflammation  in  and 
about  the  tissues  of  the  joint,  persistent  swelling  and  pain  were 
among  the  remote  disabling  effects  that  made  life  more  or  less  of  a 
burden. 

We  have  reason  to  expect  better  results  hereafter  under  modern 
conditions.  Still,  as  already  stated,  wounds  in  the  ankle  are  located  in 
rich  soil  for  the  development  of  septic  microbes.  In  spite  of  the  ample 
preparation  that  a  great  civilized  government  can  make  against  the 
occurrence  of  sepsis  in  war  wounds,  infection  occurred  in  twenty-eight 
out  of  the  forty  ankle-joint  wounds  reported  from  the  Anglo-Boer  War.^ 
It  is,  however,  gratifying  to  note  that  there  was  no  death  reported. 
Thirteen  of  the  cases  were  marked  by  perforation,  and  nine  among 
these  were  aseptic.  They  all  made  rapid  recoveries  under  a  conserva- 
tive mode  of  treatment,  but  the  majority  showed  some  limitation  of 
movement  when  invalided  home.  The  removal  of  bony  fragments 
among  the  thirteen  cases  exhibiting  perforation  was  at  no  time 
required.  Incisions  were  made  in  two  cases,  and  a  lodged  ball  was 
extracted  from  the  substance  of  the  astragalus  in  one.  In  twelve 
other  cases  operative  treatment  was  resorted  to  for  the  removal  of 
fragments  of  either  the  tibia,  fibula,  or  tarsal  bones.     Eleven  of  these 

1  Gunshot  Wounds  of  Joints  by  Lt.-Col.  S.  Hickson,  R.  A.  M.  C,  in  Stevenson's 
Report.     Harrison  &  Sons,  St.  Martin's  Lane,  London,  1905. 


330  GUNSHOT   WOUNDS 

cases  were  septic.     There  was  considerable  limitation  of  movement  in 
some  of  the  cases  and  absolute  fixation  in  others. 

The  Surgeon-General,  U.  S.  Army,  for  the  four  years  1898  to  1901, 
which  includes  the  period  of  the  Spanish- American  War  and  Philippine 
Insurrection,  reports  twenty-six  gun-shot  wounds  of  the  ankle-joint 
with  two  deaths.  Eleven  of  the  men  were  restored  to  duty,  and 
thirteen  were  discharged  on  surgeon's  certificate  of  disability.  They 
were  all  treated  conservatively  with  one  exception,  in  which  amputa- 
tion became  necessary.  We  may  take  the  cases  of  the  Spanish-Ameri- 
can and  Anglo-Boer  Wars  as  an  index  of  the  results  we  are  to  expect 
in  the  majority  of  ankle-joint  injuries  hereafter  under  modern  condi- 
tions. Conservation  is  indicated  in  the  large  majority  of  the  cases,  viz., 
in  all  except  those  in  which  the  bones  and  soft  parts  have  suffered  such 
extreme  traumatism  as  to  necessitate  immediate  amputation.  The 
rule  of  treatment  now  is  to  dress  the  wound  antiseptically  and  to 
employ  fixation  at  once.  If  fragments  have  to  be  removed  this  can 
usually  be  done  through  the  exit  wound,  as  it  is  larger  and,  when 
necessary,  it  can  be  incised  to  give  more  room.  Only  loose  fragments 
should  be  removed.  Severed  tendons  should  be  united  by  catgut  or 
silkworm-gut  suture.  The  wound  should  next  be  irrigated,  and  a 
drain  to  remain  thirty-six  to  forty-eight  hours  put  in  place. 

Fixation  is  best  accomplished  with  plaster  of  Paris.  The  splint 
should  extend  from  above  the  knee  to  the  toes  to  properly  immobilize 
the  tibia  and  fibula.  Plenty  of  window  space  opposite  the  ankle 
should  be  cut  away  to  permit  easy  access  to  the  wounds  for  redressing. 

When  the  wound  becomes  infected,  the  inflammatory  process  will 
generally  be  arrested  by  establishing  good  drainage  through  free  in- 
cisions, and  the  use  of  frequent  irrigations  with  germicide  solutions  of 
a,  necessary  strength  once  or  twice  daily.  The  after-treatment  in  the 
way  of  massage,  movement  of  the  toes,  rubbing,  and  faradization  of 
muscles  will  do  a  great  deal  toward  restoring  the  use  of  the  ankle. 

Excision  of  the  Ankle-joint. — This  operative  measure  is  only 
mentioned  here  to  be  condemned.  It  finds  no  place  in  either  the 
primary,  intermediate  or  secondary  stages  of  ankle-joint  lesion  from 
gunshot.  In  addition  to  the  fact  that  the  results  as  far  as  the  utility 
of  the  limb  were  extremely  bad  in  our  Civil  War,  according  to  Otis,  the 
mortality  of  excision  of  the  ankle  was  one-third  greater  than  that 
observed  after  the  conservative  plan  of  treatment.  The  operation 
was  not  popular  in  former  times.  Otis  records  but  thirty-three  cases  in 
the  Civil  War  with  nine  deaths — a  mortality  of  29  per  cent.     The 


GUNSHOT   WOUNDS    OF   JOINTS  331 

results  in  the  Fanco-German  War  out  of  fifty  cases  gave  an  aggregate 
mortality  of  43  per  cent.  In  the  recoveries  recorded  by  Otis  the  greater 
number  suffered  from  painful  and  swollen  joint;  fistulse  were  not  in- 
frequent, and  the  patients  almost  invariably  had  to  walk  with  the  aid 
of  crutches.  As  a  general  result,  in  excision  of  this  joint,  the  foot  is 
often  turned  in  or  out,  or  it  is  left  in  a  state  of  equino varus;  the  toes 
are  deformed,  and  walking  is  not  only  painful  but  uncertain.  Finally 
the  results  as  to  restoration  of  function  are  such  that  amputation  in  the 
lower  third  of  the  leg  has  hitherto  been  considered  preferable.  There  is 
no  account  of  excision  of  the  ankle-joint  in  either  the  Spanish-American 
or  Boer  War. 

Amputation. — We  have  already  indicated  the  conditions  that 
demand  primary  amputation.  They  relate  to  extreme  traumatism  of 
bony  and  soft  tissues  with  no  hope  of  recovering  the  use  of  the  ankle- 
joint  or  foot.  These  injuries  are  more  often  the  result  of  hits  by  shell 
fragments,  or  wounds  from  shot-guns  at  close  range,  and  they  can  also 
result  from  the  effects  of  the  modern  rifle  when  it  is  discharged  at 
contact  or  near  by.  Hickson^  reports  eleven  cases  of  amputation  out  of 
forty  injuries  to  the  ankle-joint  in  the  Boer  War.  The  operation,  as 
a  rule,  was  rendered  necessary  on  account  of  septic  conditions  associ- 
ated with  comminuted  fractures.  Shell  wounds  figured  in  five  of  the 
cases  and  three  of  these  were  done  on  the  field,  but  reamputation  was 
necessary  later  on,  from  which  the  reporter  lays  emphasis  upon  the 
mistake  which  is  often  made  of  performing  primary  amputations  at 
the  front. 

Secondary  amputation  will  be  indicated  when  infection  has 
thwarted  attempts  at  conservation.  The  limb  will  have  to  be  sacri- 
ficed at  a  point  marked  by  sound  tissues. 

1  Op.  cit. 


CHAPTER  XII 

Gunshot  Injuries  of  the  Diaphyses  of  the  Long  Bones 

The  military  surgeon  is  especially  interested  in  gunshots  of  the 
diaphyses  on  account  of  their  frequency,  their  varied  character,  the 
difficulties  which  they  offer  in  transport,  and  finally,  because  they 
always  figure  among  the  serious  wounds. 


'■^^Bm  ^^^^^^^E^ 


Fig.  137.  Fig.  138. 

Fig.  137. — Radiograph  showing  oblique  fracture  by  contact  of  Mauser  bullet  against  outer  side 
radius,  from  Spanish  American  War.     (Borden.) 

Fig.  138. — Radiogram  from  Turko-Balkan  War,  1912-13.  Oblique  fracture  from  very  slight 
guttering  of  humerus  in  a  Turkish  Infantryman  by  Bulgarian  rifle  bullet  at  Lulu  Burgas  1200  meter 
range.     War  College  collection. 

Contusions. — ^Lesions  of  this  class  are  the  result  of  direct  injury 
by  grazing,  glancing  or  direct  impact  againt  bone  from  bullets  or 
pieces  of   shell.     The  older  works,  like  those  of  Guthrie,  McLeod, 

332 


GUNSHOT   INJUEIES    OF   THE    DIAPHYSES    OF   THE    LONG  BONES     333 

Longmore  and  others  made  no  reference  to  this  form  of  injurJ^  Lidell^ 
in  our  country  was  among  the  first  to  prominently  call  attention  to 
such  cases.  He  points  out  a  fact  observed  by  others  since,  that  con- 
tusion of  the  diaphyses  in  the  lower  extremities  is  more  prone  to  lead 
to  necrosis  and  other  bone  complications  than  contusion  of  the  diaphy- 
ses in  the  upper  extremity,  because  the  latter  are  more  richlj^  endowed 


Fig.  139. — Radiogram  from  Turko-Balkan 
War,  1912-13.  Oblique  fractiire  by  Turkish  rifle 
bullet  at  Burnar-Hissar,  Oct.  30,  1912.  War  Col- 
lege collection. 


Fig.  140. — Radiogram  from  Turko- 
Balkan  War,  1912-13.  Transverse 
fracture  by  Turkish  Shrapnel.  Frag- 
ments of  shrapnel  ball  lodged  near 
elbow-joint. 


with  blood  supply.  None  of  the  cases  cited  by  Lidell  include  the 
humerus,  for  instance,  and  Otis  calls  attention  to  the  fact  that  our 
army  medical  rhuseum  collection  possesses  but  two  examples  of 
contusion  in  the  humerus  Tvdth  other  evidences  of  bone  lesion,  while 
such  instances  are  not  uncommon  in  the  femur  and  tibia.  Six  of 
Lidell's  thirteen  cases  were  due  to  spent  bullets  lodged  against  bone 
and  were  removed  through  the  wound.  Five  cases  resulted  from 
glancing  bullets,  one  a  grazing  shot.  One  resulted  in  amputation, 
five  died,  and  seven  made  more  or  less  complete  recoveries. 

^  Contusion  and  Contused  Wounds  of  Bone  with  an  account  of  thirteen  cases 
by  John  A.  Lidell,  Siu-geon  U.  S.  Vols.,  Am.  J.  Med.  Science,  Vol.  L,  1865. 


334  GUNSHOT   WOUNDS 

Contusion  of  bone  will  be  less  likely  to  occur  from  the  effects  of  the 
modern  bullet  unless  it  has  lost  its  remaining  velocit}^  before  impact, 
but  it  may  occur  from  glancing  shots  at  high  velocity.  Experiments, 
and  observations  in  war  have  shown  that  the  slightest  contact  by  a 
bullet  travelling  at  high  velocity  conveys  a  vibrator}^  force  to  the  bone 
of  sufficient  intensity  to  cause  complete  fracture.  Such  fractures  are 
often  attended  with  long  fissures  radiating  some  distance  from  the 
point  of  impact  (Figs.  137,  138,  139  and  140).  Whether  this  vibra- 
tory force  is  sufficient  to  cause  contusion  short  of  fracture  when  the 
bullet  passes  near  a  bone  just  short  of  contact  has  not  been  noted 
so  far. 

The  lesion  in  contusion  of  bone  shows  effusion  of  blood  under  the 
periosteum,  the  bone  has  lost  its  blood  supply  and  in  cases  of  cUrect 
injury  by  the  ball  there  ma}-  be  more  or  less  destruction  of  the  super- 
ficial part  of  the  bone  which  adds  to  the  existing  lesion.  The  ele- 
ment of  contusion  and  hematoma  described  augments  the  tendency 
to  the  development  of  infection,  in  which  case,  periostitis  and 
ostitis  are  prone  to  occur,  and  when  they  do  unless  they  are 
promptly  and  properly  treated,  terminal  bone  troubles,  Uke  necrosis 
with  exfoliation  of  sequestra,  or,  worse  still,  osteomyelitis  is  liable 
to  develop.  In  cases  of  injury  adjacent  to  bone,  whether  fracture  is 
present  or  not,  if  infection  sets  in,  with  the  accompamnng  train  of 
sj^mptoms  pertaining  to  inflammation  in  bone,  the  surgeon  should 
regard  the  case  as  one  of  the  acute  bone  lesions  and  treat  it 
accordingly. 

Treatment  or  Contusion. — To  forestall  sepsis  is  the  prime  indica- 
tion in  contusion  of  the  diaphyses  of  the  long  bones.  This  is  done 
by  the  use  of  antiseptic  solutions  upon  the  wound  and  the  adjacent 
skin,  or  preferably  painting  with  Tincture  of  iodine  before  applying  the 
first  clean  dressing.  The  projectile  when  lodged  against  bone  should  be 
removed  as  soon  as  it  has  been  properly  located.  The  wound  should 
next  be  thoroughly  irrigated  with  a  weak  antiseptic  solution  and  then 
immobilized.  If  the  temperature  rises,  \\dth  other  symptoms  of  acute 
inflammatorj^  process  in  bone,  a  free  incision  should  at  once  be  made 
down  to  the  latter  including  the  periosteum,  to  insure  perfect  drainage. 
If  pus  is  found  or  if  the  pain  and  temperature  continue,  the  compact 
bone  at  the  point  of  injury  should  be  trephined  down  to  the  medullary 
canal.  If  osteomyelitis  is  present,  trephining  at  several  points  may 
become  necessary.     When  the  measures  mentioned  prove  of  no  avail 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     335 

and  the  sj^mptoms  persist,  amputation  should  be  performed  at  the 
joint  next  above  the  lesion.  In  a  case  of  septic  osteomj^elitis  of  the 
femur  Major  Powell  C.  Fauntleroy,  U.  S.  Army,  and  the  author 
were  able  to  arrest  the  disease  process  by  amputating  at  the  junction 
of  the  middle  and  upper  thirds  of  the  femur,  after  which  the  medullary 
canal  remaining  was  curetted  and  swabbed  with  pledgets  of  lint  on 
a  probe,  saturated  with  a  solution  of  bichloride  of  mercury  1-1000. 

Gunshot  fracture  of  the  diaphyses  of  the  long  bones  may  be  divided 
into  (1)  simple  fractures  and  (2)  compound  fractures. 

Simple  fractures  were  more  frequent  formerly  as  a  result  of  impact 
against  a  bone  by  slow-moving  shells  or  pieces  of  hollow  shells  of  moder- 
ate size.  Such  fractures  were  also  observed  to  occur  from  the  large 
rifle  projectiles  striking  at  low  velocity  against  a  bony  part  with 
clothing  or  part  of  the  equipment  of  the  soldier  intervening  between 
the  skin  and  the  bullet.  The  force  of  impact  in  these  cases  more  often 
caused  contusion  of  soft  parts.  The  infrequency  of  simple  fracture 
from  such  traumatisms  may  be  estimated  by  the  fact  that  Otis  with 
his  vast  opportunities  to  collect  accounts  of  all  kinds  of  fractures  from 
our  Civil  War  mentions  but  nine  cases  of  simple  fracture  without  open 
wounds,  and  five  of  these  occurred  in  the  humerus.  The  amount  of 
fracture  and  contusion  of  soft  parts  will  depend  on  the  volume  and  the 
force  of  impulse  which  is  exerted  by  the  projectile.  The  fractured 
bone  may  show  comminution  or  simple  fracture,  and  in  the  long  bones 
multiple  fractures  have  been  noted.  Otis  gives  the  history  of  a  case 
in  a  sergeant  of  artillery  who  was  struck  at  the  first  battle  of  Bull 
Run  "by  a  12-pound  shot  which  fractured  the  humerus  at  three  dif- 
ferent points,  but  did  not  even  bruise  the  skin." 

Simple  fracture  of  the  diaphyses  of  all  the  long  bones  as  well  as 
those  of  the  metacarpal  and  metatarsal  bones  have  been  noted  in  the 
literature.  It  is  doubtful  if  simple  fracture  with  the  use  of  the  new 
armament  will  be  noted  as  frequently  hereafter.  Large  shot  are  mostly 
used  against  material  now,  and  except  on  board  men  of  war  in  naval 
combat  and  during  siege  operations  they  do  not  figure  among  the  causes 
of  war  wounds.  The  treatment  of  simple  fracture  from  gunshot  is 
the  same  as  that  of  simple  fracture  from  other  causes. 

(2)  Compound  fractures  by  gunshots  are  marked  by  an  open  wound 
of  the  soft  parts  leading  into  the  foyer  of  fracture.  The  lesions  in 
these  osseous  injuries  were  described  in  Chapter  II,  which  deals  with 
the  characteristic  features  of  gunshot  wounds  by  different  kinds  of  pro- 


336  GUNSHOT   WOUNDS 

jectiles  and  they  will  not  be  referred  to  here  except  to  state  that  the 
amount  of  traumatism  in  every  fracture  is  coincident  with  the  velocity 
of  the  projectile,  its  sectional  area,  and  the  resistance  offered  by  the 
bone  at  the  point  of  impact.  The  degree  of  traumatism  will  include 
grooving,  perforation  with  short  or  long  subperiosteal  fissures,  com- 
minution with  detached  fragments,  and  fissures  which  may  extend 
above  and  below  the  fracture,  as  far  as  the  adjacent  joints.  Gunshot 
fractures  of  the  diaphyses  are  numerous  in  war  hospitals.  They  form 
12  per  cent,  of  all  war  wounds  (Fischer).  According  to  Otis  those  of 
the  bones  of  the  leg  constitute  31  per  cent,  of  all  the  fractures  of  the 
long  bones;  the  humerus  28.4  per  cent.;  femur  22.6  per  cent,  and  the 
bones  of  the  forearm  17.9  per  cent. 

Follenfant^  reports  upon  the  variety  of  gunshot  fractures  exhibiting 
explosive  effects  in  the  Manchurian  campaign,  from  which  we  find  that 
operative  measures  for  the  removal  of  bone  fragments  were  not  numer- 
ous. The  Karbine  statistics  for  1904  record  the  removal  of  fragments  in 
184  cases  out  of  2845  fractures  of  the  extremities.  The  fractures  of  the 
diaphyses  showed  long  fissures  on  X-ray  plates,  as  a  rule.  The  in- 
fections were  frequent,  but  not  grave,  and  the  amputations  rendered 
necessary  were  comparatively  few  in  number,  not  exceeding  5  per  cent, 
for  all  fractures  of  long  bones.  Of  thirty-six  cases  of  tetanus  observed 
at  Karbine  in  1904  thirty-three  occurred  in  gunshots  of  the  extremities. 
The  mortality  after  gunshot  fractures  was  very  small.  Of  2845  cases 
only  thirty-nine  deaths  are  recorded  and  sixteen  of  these  occurred 
among  478  gunshot  fractures  of  the  femur.  The  rule  of  treatment  was 
almost  entirely  conservative. 

Treatment  ot  Gunshot  Fractures  ot  the  Humerus. — Of  eighty-seven 
gunshot  fractures  of  the  humerus  reported  by  the  Surgeon-GeneraP 
from  the  Spanish-American  War  and  Philippine  Insurrection  1898- 
1901  inclusive,  there  were  five  deaths  or  a  mortality  of  5.7  per  cent. 
Twenty-one  of  the  eighty-seven  cases  were  due  to  bullets,  kind  not 
stated,  thirty-two  were  caused  by  Spanish  Mausers  of  reduced  caliber, 
seven  by  Krag-Jorgensen  bullets,  four  by  revolver  bullets,  seventeen 
by  Remington  rifle  bullets,  one  by  shrapnel  ball,  one  by  piece  of  shell, 
two  by  pieces  of  steel  and  slugs.  The  disposition  of  the  cases  was  as 
follows:  Thirty-nine  or  45  per  cent,  were  restored  to  duty,  twenty- 
nine  discharged  for  disability  and  twelve  were  otherwise  discharged  the 
service.     There  were  ten  amputations  performed,  one  resection,  frag- 

1  Op.  cit. 

2  Annual  Reports,  S.  G.,  U.  S.  A.,  1898-1902. 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES       337 

ments  of  bone  were  removed  in  several  cases  and  incision  for  drainage 
was  done  in  one  case.  There  is  no  record  of  the  number  of  lodged  balls 
available. 

Hickson^  in  his  report  of  cases  in  the  South  African  War  gives  notes 
of  eighty-three  fractures  of  the  humerus  caused  by  every  variety  of 
projectiles.  Forty-two  of  the  eighty-three  cases  were  septic.  Re- 
moval of  fragments  was  done  in  twenty-two  ca^es  in  every  one  of  which 
sepsis  was  present.  There  were  thirteen  amputations  or  an  amputa- 
tion rate  of  15.6  per  cent,  and  sepsis  was  present  in  all  of  these.  There 
were  but  three  deaths  out  of  the  eighty-three  cases,  a  mortality  of 
3.6  per  cent. 

The  mortality  for  the  two  groups  cited,  those  in  the  Spanish- 
American  and  Boer  Wars,  speaks  well  for  the  modern  methods  of  wound 
treatment  in  war,  and  the  beneficence  which  comes  from  the  use  of 
reduced-caliber  rifle  bullets.  More  than  half  of  our  cases  were  due 
to  this  bullet  although  the  records  ascribe  many  of  the  wounds  due  to 
"bullet"  in  the  returns,  a  convenient  term,  employed  by  surgeons 
generally.  For  instance  of  the  eighteen  cases  from  the  battle  of 
Santiago,  twelve  are  put  down  as  due  to  bullets  when  as  a  matter  of 
fact  we  know  that  they  were  nearly  all  due  to  injury  by  the  Spanish 
Mauser. 

Conservative  Treatment. — Conservation  should  be  practised  in 
all  gunshot  injuries  of  the  humerus,  except  those  in  which  the  nec- 
essary blood  and  nerve  supplies  of  the  arm  have  been  destroyed, 
regardless  of  the  amount  of  comminution.  In  preantiseptic  times 
surgeons  often  sacrificed  arms  on  account  of  extensive  bone  lesion  that 
are  prefectly  amenable  to  treatment  now.  Under  our  present  method 
of  wound  treatment,  we  look  for  consolidation  of  fragments,  however 
numerous,  provided  they  are  attached  to  periosteum  or  soft  tissues 
which  give  them  blood  supply.  We  look  for  consolidation  even  in 
cases  where  there  is  loss  of  bone  substance  in  continuity  for  1  or  2 
inches.  Nature  will  fill  the  gap  with  callus  in  time.  To  insure  all 
these  expectations  on  the  part  of  nature  it  is  necessary  first  of  all  to 
exclude  sepsis,  and  the  fate  of  the  limb  will  depend  upon  the  surgeon's 
ability  to  maintain  asepsis.  To  this  end  the  skin  and  wound  are  to  be 
cleansed  thoroughly  by  scrubbing  with  soap  and  water,  and  by 
irrigation  with  antiseptic  solutions.  To  facilitate  exploration  the  exit 
wound,  which  is  usually  larger,  and  near  which  the  bulk  of  fragmenta- 
tion is  found,  should  be  enlarged  by  incision  when  necessary.     Frag- 

1  Op.  cit. 


338  GUNSHOT   WOUNDS 

ments  which  still  adhere  should  be  replaced  as  near  as  possible  to  their 
normal  position,  after  they  have  been  released  from  any  entanglement 
with  the  soft  parts,  and  those  fragments  which  are  entirely  detached 
should  be  removed.  In  wounds  showing  explosive  effects  it  is  not 
unusual  to  find  fragments  buried  in  the  tissues  2  and  3  inches  from  the 
point  of  fracture.  The  wound  should  be  dressed  antiseptically,  a 
drain  put  in  place  to  be  retained  twenty-four  to  forty-eight  hours, 
and  the  limb  immobilized,  including  both  the  shoulder-  and  elbow- 
joints  with  the  fore-arm  flexed  at  a  right  angle.  Immobilization 
should  be  accomplished  by  the  splints  ordinarily  used  in  surgical 
practice,  but  plaster  of  Paris  as  a  fixed  dressing  should  be  given  pref- 
erence whenever  it  can  be  conveniently  employed. 

In  the  lesser  degrees  of  fracture,  and  in  aseptic  cases  especially, 
exploration  with  a  view  to  removal  of  detached  fragments  will  not  be 
necessary.  Beyond  cleansing  the  skin  near  the  wound,  a  clean  dressing 
and  fixation  of  the  limb  as  above  stated,  there  is  but  little  to  be  done. 

Hickson  states  that  the  most  noticeable  feature  among  the  after- 
effects of  the  eighty-three  cases  from  the  South  African  War  was  the 
frequency  of  nerve  injuries,  especially  the  musculo-spiral.  The  large 
nerves  were  seldom  cut  by  the  projectiles,  the  lesions  were  a  result  of 
direct  pressure  by  callus  or  fibrous  bands. 

Non-union  in  fractures  of  the  humerus,  which  F.  H.  Hamilton  and 
others  of  our  great  authors  have  so  often  noted  in  civil  practice,  is 
happily  very  infrequent  in  military  practice.  Of  2900  cases  of  gun- 
shot fracture  of  the  humerus  in  our  Civil  War  Otis  records  but  six 
cases  of  pseudarthrosis  and  two  of  these  were  after  simple  fracture. 
Neurdorfer^  states  that  he  has  not  met  with  a  single  case  in  all  of  his 
military  practice  as  a  result  of  shot  fracture.  Non-union  in  civil  prac- 
tice has  generally  been  attributed  to  the  difficulty  of  properly  immobi- 
lizing the  broken  fragments.  Sedillot^  ascribed  the  generally  uniform 
union  of  fractures  after  gunshots  to  the  extent  and  activity  of  the 
osteogenetic  process. 

Excision  in  continuity  was  once  advocated  by  military  surgeons 
and  during  our  Civil  War  it  was  practised  more  than  any  time 
before  or  since.  In  badly  comminuted  fractures  the  older  surgeons 
indulged  the  hope  that  a  formal  excision  would  be  attended  with  less 
danger  than  an  attempt  at  conservation,  but  the  faithful  and  costly 

iHandbuch  der  Kriedschirurgie,  1872,  B.  II,  S.  1179. 

2  Du  Traitment  des  Fractures  des  membres  par  Armes  a  Feu  Arch.  Gen.  de 
Med.,  Ser.  VI,  T.  XVII,  P.  I. 


GUNSHOT   INJURIES    OF   THE    DIAPHYSES    OF   THE    LONG  BONES     339 

attempts  in  our  Civil  War  had  the  tendency  to  array  the  dictum  of  the 
profession  against  the  practice,  so  that  it  is  no  longer  advocated  as  an 
operative  measure.  Otis  significantly  calls  attention  to  the  fact  that 
in  the  696  cases  of  excision  in  continuity  in  our  Civil  War  the  aggre- 
gate mortality  rate  was  28.5  per  cent.  This  mortality  is  12  per  cent, 
higher  than  that  in  a  larger  series  of  primary  amputations  in  the  upper 
third  of  the  arm  and  nearly  double  that  observed  in  3005  cases  treated 
by  conservation.  Among  those  who  recovered  after  excision  in  con- 
tinuity, one-third  had  "no  bony  union"  or  "false  joint";  a  number 
suffered  consecutive  amputation  of  the  arm;  and  more  still  suffered 
ultimate  exarticulation  or  amputation  with  a  mortality  of  nearly  50 
per  cent.  The  remonstrance  which  Otis  made  to  the  operation  was 
accepted  bj^  men  like  Ashurst,  Hamilton,  and  Gross  in  this  country, 
and  MacCormac  in  England.  Under  our  present  mode  of  treatment 
we  practise  conservation  in  all  the  cases  where  excision  in  continuity 
was  practised  in  the  time  of  our  Civil  War.  If  we  exclude  sepsis 
from  the  foyer  of  fracture,  callus  will  form  to  fill  whatever  gap  may 
arise  from  loss  of  bone  substance.  Cases  with  loss  of  much  bone  in 
continuity  can  now  occur  onl^^  from  shell  wounds  and  from  hand 
weapons  when  discharged  at  short  range,  producing  explosive  effects. 
Experience  has  taught  us  that  such  a  wound  treated  conservatively 
by  cleaning  the  field  and  the  wound,  removing  loose  fragments,  and 
immobilizing  the  limb,  is  attended  with  less  mortality  than  excision 
in  continuity  or  a  formal  attempt  to  fill  the  gap  by  evening  up  the 
irregularity  of  the  fractured  ends  with  a  saw,  and  then  bringing  the 
fragments  together  with  wire,  etc. 

Primary  amputation  of  the  arm  is  only  justified  in  hopeless  de- 
struction of  soft  parts,  including  the  large  vessels  and  nerves  of 
the  arm.  The  great  value  of  the  upper  extremity  to  the  patient's 
struggle  for  existence  causes  a  surgeon  to  weigh  well  the  nature  of  the 
injury  and  the  condition  of  the  patient,  before  he  resorts  to  amputa- 
tion. The  loss  of  an  upper  extremity  is  of  such  moment  to  the  patient 
that  he  is  often  willing  to  take  a  certain  risk  on  his  life  before  giving  his 
consent.  Aside  from  this  objection  to  primary  amputation  the  older 
surgeons  were  fully  cognizant  of  the  wonderful  resources  of  nature  to 
restore  a  badty  comminuted  arm  to  its  former  utility.  Non-union  was 
seldom  noted,  and  many  of  the  military  surgeons  like  Guthrie  and 
Longmore  were  loath  to  sacrifice  an  arm,  in  spite  of  extensive 
comminution,  including   injury  to  the  brachial  artery. 

These  views  on  amputation  were  entertained  by  the  majority  of 


340  GUNSHOT    WOUNDS 

the  Confederate  surgeons  in  our  Civil  War.^  They  were  largely 
guided  by  the  following  advice  from  Longmore:  "Unless  the  bone 
be  extremely  injured  by  a  massive  projectile,  or  longitudinal  com- 
minution exist  to  a  great  extent,  especially  if  it  also  involves  a  joint, 
or  the  state  of  the  patient's  health  be  very  unfavorable,  attempt  should 
always  be  made  to  preserve  the  upper  extremity  after  a  gunshot  wound." 
These  views  held  by  the  majority  of  the  world's  surgeons  were  not 
shared  by  those  of  our  army  between  1861-65,  during  which  period, 
out  of  8245  gunshot  fractures  of  the  humerus  unattended  by  primary 
injury  of  the  shoulder-  or  elbow-joints,  there  were  3259  primary 
amputations  of  the  arm  in  the  continuity  of  the  humerus  with  a 
mortality  of  18.4  per  cent.  The  record  shows  that  the  surgeons  in 
the  Union  Army  practised  primary  amputation  in  39.5  per  cent,  of 
the  8245  gunshot  fractures  of  the  humerus.  Considering  the  consensus 
of  opinion  against  the  practice  before  and  since,  the  percentage  is 
large,  but  Otis  offers  explanations  that  go  far  to  exonerate  the  field 
surgeons  of  the  charge  of  sacrificing  limbs  without  cause.  Certainly 
many  of  the  primary  amputations  that  were  performed  were  absolutely 
necessary  on  account  of  extensive  lacerations  by  cannon  shot  with 
injury  to  vessels  and  nerves.  There  still  remained  a  very  large  number 
in  which  amputation  was  performed  because  of  extensive  comminution 
of  the  shaft  by  the  projectiles  of  hand-weapons.  Considering  the 
dangers  of  sepsis  which  then  prevailed,  and  the  unfavorable  environ- 
ments which  precluded  the  adoption  of  proper  conservative  efforts,  on 
account  of  the  absence  of  adequate  hospital  facilities,  and  the  absence 
of  safe  and  suitable  transportation,  Otis  states  that  the  surgeons  very 
properly  adopted  what  John  Bell  called  "an  argument  of  necessity  as 
well  as  of  choice,  and  limbs  that  in  happier  circumstances  might  have 
been  preserved  had  often,  in  a  flying  army  or  a  dangerous  campaign, 

to  be  cut  off; it  is  less  dreadful  to  be  dragged  along  with 

a  neat  amputated  stump,  than  with  a  swollen  and  fractured  limb, 
where  the  arteries  are  in  constant  danger  from  the  splintered  bones." 
The  plan  of  amputating  amid  such  surroundings  sacrificed  many  limbs, 
but  at  the  same  time  we  must  admit  that  it  was  attended  with  the 
saving  of  many  lives. 

According   to   Chauvel   and   Nimier,  Legouest,   and   Delorme,   a 

1  Warren  (E).  An  epitome  of  Mil.  Surgery,  1863,  p.  372,  and  Chilsolm  (J  J). 
A  Manual  of  Mil.  Surgery,  1863,  p.  386,  and  also  a  Manual  of  Military  Surgery 
prepared  for  the  use  of  the  Confederate  States  Army,  by  order  of  the  Surgeon- 
General,  C.  S.  A.,  Richmond,  1863. 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES       341 

comminuted  fracture  of  the  humerus  complicated  by  injury  to  the 
brachial  need  not  necessarily  be  a  cause  for  amputation  in  all  cases. 
For  instance,  when  the  brachial  is  severed  sufficiently  low  to  insure  the 
supply  of  the  superior  profenda,  a  policy  of  expectancy  can  be  followed, 
watching  meantime  for  the  first  sign  of  the  occurrence  of  gangrene; 
but  Delorme  would  do  an  amputation  when  the  artery  is  severed  as 
stated,  if  the  anastomotica  magna  is  also  wounded.  In  other  words, 
these  authors  believe  there  is  no  indication  for  amputation  as  long  as 
the  location  of  the  wound  in  the  branchial  is  such  that  its  collateral 
circulation  is  not  endangered. 

In  the  confusion  and  pressure  for  time  and  trained  assistants 
that  prevail  in  field  conditions,  the  attention  which  it  is  necessary  to 
bestow  on  a  gunshot  fracture  with  injury  to  the  brachial  in  accordance 
with  the  foregoing  rules,  it  not  justified.  The  point  made  by  these 
authors  should,  however,  be  borne  in  mind  as  it  may  exceptionally 
find  application  under  more  favorable  environments. 

Secondary  amputation  more  often  became  necessary  in  preantisep- 
tic  times  on  account  of  secondary  hemorrhage,  persistent  infection  in 
bones  and  soft  parts,  and  for  remote  effects  such  as  useless  and  painful 
limbs.  Out  of  the  5456  amputations  of  the  humerus  for  shot  injury  in 
our  Civil  War  there  were  411  secondary  amputations  with  a  mortality 
of  27.7  per  cent. 

Secondary  amputations  will  be  far  less  often  noted  in  future 
wars.  The  success  which  modern  surgeons  obtain  in  saving  limbs 
will  no  doubt  cause  useless  limbs  to  become  one  of  the  most  frequent 
causes  for  secondary  amputation.  It  certainly  forms  one  of  the 
frequent  causes  of  amputation  in  Soldiers'  Homes. 

Gunshot  Fracture  of  the  Forearm. — Gunshot  wounds  of  the  left 
forearm  are  more  frequent,  and  they  are  attended  with  greater 
mortality  than  gunshot  wounds  of  the  right  forearm  (Chauvel  et 
Nimier) .  Without  offering  any  reason  for  the  latter,  these  authors  make 
the  further  statement  that  gunshot  wounds  of  the  left  leg  are  more 
frequent  than  those  of  the  opposite  side,  and  that  they  are  also  attended 
with  greater  mortality.  From  10  to  15  per  cent,  of  all  fractures  in  war 
are  noted  as  fractures  of  the  bones  of  the  forearm.  The  ulna  and  radius 
may  be  fractured  together  or  independently.  In  shots  disposed  antero- 
posteriorly  or  vice  versa  but  one  bone  is  usually  fractured,  while  shots 
directed  obliquely  or  transversely  are  most  apt  to  be  attended  by 
fracture  of  both  bones.  The  amount  of  fracture  may  range  from 
guttering  and  partial  fracture  to  complete  fracture. 

LIBRARY  OF  THE 

ALUMN!  ASSOCIATIO^ 

COLLEGE  OF  PHYSiCIANS  Af^DSURGP 
COLUMBIA  UNIVLkSnY 


342 


GUNSHOT   WOUNDS 


The  bones  of  the  forearm,  except  at  their  epiphyseal  ends,  are  hard 
and  brittle,  furthermore  the  compactsubstance  is  thin,  all  of  which  ac- 
counts for  the  limited  foyer  of  fracture  and  Assuring  usually  observed  in 
these  bones.     The  area  of  fracture  may  be  extensive  at  times  as  observed 


Fig.  141.  Fig.   142. 

Fig.  141. — Fracture  showing  comminution  with  detached  fragments  involving  radius  and  ulna 
by  bullet  from  .45  cal.  Colt's  new  sendee  revolver  at  75  yards,  in  cadaver.  Bullet  and  metallic  frag- 
ments from  it  are  lodged.     Army  Med.  School  collection.     Gibbs  X-ray  Laboratory. 

Fig.  142. — Fracture  with  detached  fragments  from  .30  cal.  Krag-Jorgensen  bullet  as  a  re- 
sult of  slight  grooving  on  internal  border  of  bone.  From  Philippine  Insurrection.  Army  Medical 
School  collection. 


in  fractures  involving  the  two  bones.  In  such  cases,  the  first  bone  hit 
fragments,  and  its  spiculse,  acting  as  secondary  missiles,  make  an  im- 
pact with  the  projectile  on  the  second  bone  causing  more  than  the  usual 
amount  of  bone  comminution  and  injury  to  soft  parts  (Figs.  141, 142  and 


GUNSHOT   INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     343 

143) .  The  explosive  type  of  fracture  is  especially  common  in  the  ulna 
as  a  result  of  its  subcutaneous  position,  and  for  a  like  reason  the  same 
explosive  type  is  more  commonly  exhibited  in  the  lower  third  of  the  fore- 
arm, when  fracture  of  one  or  both  bones  occurs.  On  account  of  the 
proximity  of  the  arterial  vessels  to  bone,  injury  to  blood-vessels  and 


Antero-posterior.  Lateral. 

Fig.  143. — Radiogram  showing  two  views  in  case  of  Pvt.  Dennis  M.,  late  pvt.  Co.  "G,"  9th 
U.  S.  Inf.,  wounded  at  Tiensin,  China,  during  Boxer  Rebellion,  July  13,  1900,  by  large  caliber  lead 
bullet  at  150  yards.  Skiagram  taken  Feb.  1901.  Remote  effects:  paralysis  of  wrist  and  hand  with 
pain  in  forearm  and  elbow.  Very  slight  movement  in  extensor  tendons  of  fingers.  Marked  impair- 
ment of  hand  and  fingers  in  the  distribution  of  radial  and  median  nerves.  Army  Medical_School 
collection. 


hemorrhage,  are  among  the  frequent  complications  of  gunshot  fracture 
in  the  forearm.  Injury  to  the  interosseous  arteries  is  especially 
common. 

From  the  statistics  of  the  Spanish-American  and  Boer  Wars  we 
find  as  follows:     Of  114  cases  of  gunshot  fractures  of  the  forearm 

23 


344  GUNSHOT   WOUNDS 

reported  by  the  Surgeon-General,  U.  S.  Army,  for  the  years  1898-1902,^ 
thirty-six  were  caused  by  reduced-caliber  bullets,  mostly  Spanish 
Mausers,  sixteen  by  Remington  bullets,  forty  by  bullets,  six  by  revolver 
bullets,  two  by  slugs,  two  by  shell,  two  by  cannon,  three  by  explosion 
of  powder,  one  by  shrapnel,  one  by  explosion  of  a  cartridge.  The 
large  majority  of  these  fractures  appear  to  have  resulted  from  the 
projectiles  of  hand  weapons.  Ten  of  the  cases  or  8.3  per  cent,  suffered 
amputation,  with  one  death — the  only  death  recorded.  Bone  frag- 
ments were  removed  in  ten  cases,  resection  was  done  in  one  case,  and 
lodged  balls  were  removed  in  five  cases.  Fifty-six  of  the  cases  or 
49.1  per  cent,  were  restored  to  duty,  forty-four  were  discharged  for 
disability,  while  the  remainder  were  mustered  out,  discharged  by 
order,  etc. 

Of  sixty  cases  of  gunshot  fractures  of  the  forearm  reported  by 
Hickson^  from  the  Anglo-Boer  War,  none  terminated  fatally.  The 
radius  was  involved  in  twenty-seven  cases,  the  ulna  in  eighteen,  and 
both  radius  and  ulna  in  fifteen  cases.  Of  fifteen  cases  exhibiting 
fracture  of  both  bones  twelve  were  septic.  Amputation  was  resorted 
to  in  three  cases. 

Of  the  twenty-seven  cases  of  fracture  of  the  radius  alone,  sixty 
per  cent,  were  septic,  there  was  one  amputation  for  gangrene  from 
injury  to  the  brachial  at  its  bifurcation.  Fragments  of  bone  were 
removed  in  about  40  per  cent,  of  the  cases. 

Of  eighteen  cases  of  fracture  of  the  ulna,  all  but  two  were  septic. 
Amputation  was  necessary  in  two  cases,  one  as  a  result  of  gangrene, 
the  other  as  a  result  of  extreme  injury  to  bone  and  soft  parts. 

Treatment. — With  our  modern  methods  of  treatment  conserva- 
tion, with  very  few  exceptions,  is  the  rule  of  treatment  in  all  gunshot 
fractures  of  the  forearm.  A  limb  is  never  condemned  to  amputation 
except  in  cases  of  extreme  traumatism  of  the  soft  parts,  bones,  and 
laceration  of  nearly  all  the  principal  arteries.  During  our  Civil  War 
out  of  5194  gunshot  fractures  of  the  forearm,  the  precise  seat  of  injury 
was  specified  in  4334  cases,  and  of  this  number  the  ulna  and  radius 
were  fractured  in  1291  cases.  There  were  1007  primary  ampu- 
tations with  a  mortality  of  9.5  per  cent,  and  the  majority  of  these 
were  for  gunshot  fracture  of  both  bones.  Excluding  one  hundred 
and  forty-three  amputations  practised  for  extreme  traumatism  as  a 
result  of  injury  by  cannon  balls,  shells,  or  fragments  from  torpedoes, 

^Annual  Reports  of  the  Surgeon-General,  U.  S.  Army,  for  1899-1903. 
2  Op.  cit. 


GUNSHOT   INJURIES    OF   THE    DIAPHYSES    OF   THE    LONG   BONES     345 

we  have  a  total  of  854  instances  of  amputations  which  were  done  on 
account  of  lesions  arising  from  the  projectiles  of  hand  weapons.  There 
were  also  nearly  1000  excisions  done  for  injury  to  the  bones  of  the 
forearm,  "of  which  a  very  small  proportion  were  attended  by  absolute 
destruction  of  the  parts  by  large  projectile  or  explosions,  or  by  injuries 
of  all  the  principal  blood-vessels  or  nerves."  This  large  proportion 
of  amputations  and  excisions  was  subsequently  condemned  by  Otis 
as  unnecessary,  the  excisions  added  to  the  mortality  and  seldom  im- 
proved the  utility  of  the  limb  among  those  who  survived.  This 
mania  for  operative  work  is  ascribed  by  Otis  to  the  number  of  "inex- 
perienced medical  officers,  hastily  summoned  to  the  field  in  emer- 
gencies." Otis  shows  that  the  greater  number  of  operations  were 
performed  during  the  earlier  part  of  the  war  and  that  mature  judgment 
and  experience  condemned  the  practice  later.  Amputation,  except  for 
the  reasons  already  mentioned,  was  frowned  upon  by  all  of  the  noted 
authorities  at  that  time,  and  with  our  present  methods  of  wound  treat- 
ment conservation  finds  additional  emphasis.  Conservation  should 
always  be  practised  in  gunshot  fracture  of  one  bone,  although  com- 
plicated by  wound  of  one  or  the  other  of  the  larger  arteries.  Delorme 
even  advocates  conservation  in  cases  where  both  arteries — the  ulnar 
and  radial — are  involved,  provided  the  interosseous  arteries  are  not 
injured.  The  rule  is  never  to  resort  to  amputation  except  in  those 
cases  where  both  bones  are  fractured  and  the  large  arteries  are  severed, 
or  when  extensive  traumatism  of  the  bone  and  soft  parts  occurs  from 
shell  fragments,  implicating  also  the  median  and  ulnar  nerves. 

When  conservation  is  decided  upon,  bleeding  vessels  should  be 
tied,  severed  tendons  and  nerves  should  be  sutured,  and  all  detached 
fragments  removed.  The  wound  should  then  be  irrigated  with  an 
antiseptic  solution,  drainage  provided  for  and  the  limb  immobilized. 
The  latter  can  be  accomplished  by  straight  forearm  splints  or  pref- 
erably plaster  of  Paris.  Massage  of  the  fingers,  wrist  and  elbow 
should  be  practised  early  during  convalescence  to  preserve  the  utility 
of  the  arm  and  hand. 

Excision  in  the  continuity  of  the  bones  of  the  forearm  for  gunshot 
was  never  considered  a  favorite  operation  in  mihtary  surgery.  Of 
965  cases  of  excision  at  all  clinical  stages  in  our  Civil  War  the  mor- 
tality was  11.2  per  cent.,  while  in  2943  cases  treated  by  expectation 
it  was  but  6.4  per  cent.  In  addition  to  the  objection  on  the  score  of 
mortality,  Otis  states  that  he  was  unable  to  find  a  single  instance 
with  a  satisfactory  result,  concerning  the  utility  of  the  limb. 


346  GUNSHOT    WOUNDS 

The  operation  has  found  no  adherents  in  recent  times.  Con- 
servation, removal  of  detached  fragments,  and  rigid  antisepsis  render 
excision  at  any  time  entirely  unnecessary. 

Amputation. — We  sacrifice  the  limb  in  gunshot  of  the  forearm 
when  both  bones  are  fractured,  and  the  larger  arteries  are  severed,  or 
when  extensive  traumatism  of  the  bones  and  soft  parts  occurs  from  shell 
fragments  implicating  the  median  and  ulnar  nerves.  Ten  amputations 
of  the  forearm  for  gunshot  fracture  are  reported  from  the  Spanish- 
American  War  with  one  death.  Five  cases  suffered  amputation  in  the 
Anglo-Boer  War  with  no  death. 

Gunshot  Wounds  of  the  Hand. — Out  of  105,786  shot  wounds 
during  the  last  year  of  our  Civil  War  Otis  found  that  5.3  per  cent,  were 
of  the  metacarpus  and  4.9  per  cent,  were  of  the  phalanges  or  fingers. 
Out  of  a  total  of  11,369  gunshot  wounds  of  the  hand  during  the 
whole  of  the  same  war  there  was  an  aggregate  mortality  of  only 
3.1  per  cent.  The  modern  notion  that  gunshot  injury  of  the 
hand  is  prone  to  the  development  of  tetanus  is  rather  negatived  by 
Otis'  statistics,  since  only  twenty-four  cases  supervened  out  of  the 
large  series  referred  to.  The  occurrence  of  tetanus  from  gunshot 
of  this  region  has  received  special  attention  by  the  surgeons  of  this 
country  in  connection  with  toy-pistol  injuries  to  which  we  have 
already  referred. 

The  character  of  the  lesion  in  the  metacarpal  bones  by  the  modern 
rifle  bullet  consists  of  comminution  to  a  greater  or  less  extent  with  an 
occasional  example  of  grooving  or  perforation.  Transverse  shots 
across  the  metacarpal  bones  of  the  hand,  and  also  shots  similarly 
disposed  across  the  metatarsal  bones  of  the  foot,  are  prone  to  show 
particles  of  lodged  metal  on  X-ray  plates.  This  fact  has  been  com- 
mented upon  by  experimenters  and  by  surgeons  who  have  described 
the  characteristic  features  of  gunshot  wounds  in  recent  campaigns. 
It  has  seemed  strange  that  a  resistant  projectile,  armored  with  a 
steel  jacket  that  usually  withstands  the  hardness  of  the  long  bones 
like  the  femur  and  tibia,  should  disintegrate  on  impact  against  a 
number  of  small  thin  brittle  bones,  like  those  of  the  metacarpal  in  the 
hand.  The  reason  for  this  seems  to  lie  in  the  fact  that  the  bullet  is 
deflected  for  the  want  of  proper  support  after  passing  through  the 
first  or  second  bone  and  that,  as  it  commences  to  make  an  irregular 
impact,  when  still  possessed  with  sufficient  momentum,  the  pressure 
which  is  exerted  on  the  sides  of  the  bullet  causes  its  nucleus  to  separate 
more  or  less  from  the  j  acket  with  a  tendency  to  d isin tegration  of  the  whole 


GUNSHOT   INJURIES    OF   THE    DIAPHYSES    OF   THE    LONG   BONES     347 

bullet,  hence  the  pieces  of  metal  that  remain  lodged.  Ordnance 
officers  have  seen  the  same  thing  occur  in  projectiles  when  fired 
against  certain  thicknesses  of  armor  plate  placed  one  behind  the  other, 
and  disposed  at  short  intervals.  Projectiles  that  find  proper  support 
while  penetrating  a  target  of  solid  metal  hold  their  original  shape,  but 


Fig.  14-i.— Radiogram  in  case  of  James  M.  Denn,  9oth  Regiment  Penn.  Vois.  shows  lodged 
Minie  ball  in  palm  right  hand  since  the  battle  of  Spottsylvania,  May  10,  1864.  Ball  entered  dorsum 
2  cm.  behind  metacarpo-phalangeal  joint  opposite  point  of  lodgment.  Ball  lies  imbedded  in  a 
cyst  which  has  developed  from  the  synovial  sheath  of  the  flexor  tendon  of  the  thumb.  Ball  removed 
by  the  author  at  the  U.  S.  Soldiers  Home,  June  26,  1902.  Missile  was  loose  in  a  thick  sac  under 
palmor  fascia.  Sac  contained  about  1  ounce  of  hemorrhagic  fluid,  the  blood  being  no  doubt  the 
result  of  frequent  traumatisms  from  shaking  the  hand  violently  near  the  ears  of  his  friends  to  cause 
them  to  hear  the  ball  rattle  in  the  cyst.  The  succussiou  sound  made  by  the  loose  ball  and  the 
fluid  in  the  unyielding  sac  was  very  perceptible  to  the  sense  of  hearing.  Radiogram  was  taken 
June  26,  1902,  38  years  after  the  injury.  U.  S.  Soldier's  Home  Hospital  Laboratory,  Dr.^A._B. 
Herrick,  X-rayist. 

they  generally  break  up  when  fired  against  a  target  composed  of  a 
number  of  plates  as  above  described. 

The  mortality  from  gunshots  of  the  hand  under  modern  conditions 
is  very  small.  Out  of  470  cases  reported  by  the  Surgeon-General, 
U.  S.  Army,  for  the  years  1898-1902,^  there  were  five  deaths.     One 

1  Annual  Reports  S.  G.,  U.  S.  A.,  for  1899-1903. 


348 


GUNSHOT   WOUNDS 


of  these  was  due  to  tetanus,  one  to  septicemia,  one  from  gangrene 
which  necessitated  amputation  at  the  shoulder,  and  the  other  two  were 
due  to  causes  not  related  to  the  injury.  Wounds  of  the  hand  are 
generally  septic.  Of  thirty  cases  noted  by  Hickson  in  the  Boer  War 
twenty-six  or  86.6  per  cent,  were  infected. 

Treatment. — The  most  rigid  antisepsis  should  be  used  from  the 
beginning.  The  application  of  a  first-aid  dressing  alone  should 
not  be  considered  sufficient  in  gunshots  of  the  hand.     The  whole  hand 


Fig.  145. — Radiogram  in  case  of  Pvt.  A.  Co— Reg— U.  S.  Army.  Shot  with  .32  Winchester  rifle 
at  Ft.  Custer,  Mont.,  1882.  (1)  Bullet  and  a  fragment  lodged  near  greater  trochanter.  (2)  Sup- 
purating sinuses  marked  by  bismuth  injections.  Biillet  removed  by  Col.  Crosby,  iSIed.  Corps, 
U.  S.  A.,  at  Soldiers  Home,  Sept.  1911.     Army  Medical  School  collection. 


should  be  painted  with  tincture  of  iodine  or  thoroughly  scrubbed 
with  soap  and  water  and  the  wound  thoroughly  irrigated  ^\'ith  bichlo- 
ride of  mercury  1-2000.  Detached  spiculse  of  bone  should  be  re- 
moved, drainage  provided  for,  and  after  the  apphcation  of  a  clean 
dressing  the  hand  and  forearm  up  to  the  elbow  should  be  immo- 
bilized. If  sepsis  sets  in,  the  continuous  arm  bath  will  be  of  great 
service;  and  if  suppuration  is  impending  free  incisions  and  thorough 
drainage  should   be   practised   early.     In  extensive  comminution  of 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     349 

the  phalanges  and  metacarpal  bones  the  surgeon  should  make  every 
effort  to  preserve  as  much  of  the  injured  part  as  may  be  consistent 
with  even  a  partial  degree  of  utility.  The  advantage  of  preserving 
one  or  more  fingers,  as,  for  instance,  the  thumb  and  one  finger  or  the 
index  finger  alone,  is  of  great  value. 

Gunshot  Injuries  of  the  Shaft  of  the  Femur. — There  were  6738 
shot  injuries  of  the  femur  in  our  Civil  War,  of  which  162  were  classed 
as  contusions  and  6576  as  gunshot  fractures. 


Fig.  146. — A  recent  skiagram  showing  lodged  eonoidal  bullet  against  bone  in  old  soldier  wounded 
in  Civil  War,  1861-6.5.  Reported  by  Lt.  Col.  George  DeShon,  Med.  Corps,  U.  S.  Army.  Army 
and  Navy  Genl.  Hospital,  Hot  Springs,  Ark.     X-ray  Laboratory. 

Shot  Contusion  of  the  Shaft  of  the  Femur. — The  contusions  of 
the  femur  from  gunshots  were  more  frequent  than  those  of  the  humerus 
already  referred  to.  Otis  records  that  amputation  became  necessary 
in  nine  instances  with  seven  fatal  results,  a  mortality  of  77.7  per  cent., 
while  the  remainder  153  were  treated  conservatively  without  operation 
\\ath  a  mortality  of  22.8  per  cent.  (Figs.  145  and  146). 

There  is  no  reference  to  contusion  from  gunshots  of  bone  in  recent 
wars.  The  lesion  is  evidently  more  rare  with  the  new  armament,  or 
the  present  method  of  wound  treatment,  which  tends  to  keep  wounds 


350  GUNSHOT    WOUNDS 

aseptic,  does  away  with  the  inflammatory  comphcations  that  formerly 
unmasked  the  lesion.  Still  we  might  naturally  expect  a  larger  per- 
centage of  gunshot  contusions  with  the  use  of  the  old,  larger-caliber 
lead  bullets,  than  from  the  highly  penetrating  rifle  bullets  of  the  present 
day,  which  seldom  lodge. 

Gunshot  Fractures  of  the  Shaft  of  the  Femur. — Shot  fractures 
of  the  femur  occurred  in  26.9  per  cent,  of  all  gunshot  fractures,  and 
they  formed  2.3  per  cent,  of  all  wounds  in  our  Civil  War  hospitals. 
The  mortality  in  6576  recorded  cases  was  as  follows:  for  the  upper 
third  49.7  per  cent.;  middle  third  46.1  per  cent.;  the  lower  third 
42.8  per  cent. 

The  foregoing  statistics  agree  in  the  main  with  the  results  following 
similar  injuries  in  the  wars  before  the  introduction  of  antisepsis  and  the 
change  in  armament. 

In  recent  wars  we  have  gathered  enough  data  to  show  a  marked 
change  for  the  better  in  the  outcome  of  gunshot  fractures  of  the  femur. 
There  were  132  cases  of  gunshot  fracture  of  the  femur  in  the  Spanish 
American^  War  with  a  death  rate  of  14.3  per  cent.;  and  170  cases  were 
recorded  for  the  Boer  War^  with  a  mortality  of  17  per  cent.  Of  the 
132  cases  from  the  Spanish- American  War  the  projectiles  of  the  hand 
weapons  were  responsible  for  97  per  cent,  of  the  fractures,  and  at 
least  75  per  cent,  of  these  were  the  result  of  shots  from  the  reduced- 
caliber  rifles.  Shell  and  shrapnel  only  caused  two  fractures  each. 
The  greater  mortality  in  the  British  returns  from  the  Anglo-Boer  War 
was  doubtless  due  to  the  greater  number  of  severe  fractures  from 
artillery   fire.     Hickson   states   that    "a   considerable   number  were 

due    to    shell    wounds including    the    Vickers-Maxim." 

Otherwise  the  cases  from  the  two  wars  were  quite  similar.  They 
were  inflicted  in  battle  for  the  most  part,  and  they  received  the  same 
treatment  and  about  the  same  care  and  attention.  If  we  group  the 
cases  of  the  two  wars  together  we  have  302  cases  of  gunshot  fracture 
of  the  femur  which  under  modern  conditions  give  a  mortality  of  15.8 
per  cent.  By  deducting  this  percentage  from  46.2  per  cent.,  which 
was  the  mortality  of  gunshots  of  the  femur  in  the  Civil  War,  we  find 
the  gratifying  reduction  of  30.4  per  cent,  in  the  mortality  of  gunshot 
fractures  of  the  thigh  under  modern  conditions  as  compared  to  the 
mortality  in  preantiseptic  times. 

Treatment    by    Conservation. — Under    modern    conditions    the 

1  Annual  Report  S.  G.,  U.  S.  A.,  1899-1902. 
^Lt.-Col.  S.  Hickson,  op.  cit. 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     351 

large  majority  of  gunshot  fractures  of  the  femur  are  treated  by  con- 
servation. This  mode  of  treatment  is  appHcable  in  all  cases  except 
those  attended  by  extensive  comminution,  laceration  of  soft  parts, 
and  destruction  of  the  main  vessels  and  nerves. 

Until  1848,  the  treatment  followed  by  military  surgeons  in  fractures 


Fig.  147. — Figs.  147,  148  and  149  show  the  happy  results  in  a  gun-shot  fracture  treated  by 
modern    conservative    methods. 

Pvt.  Harvey  B.,  27th  Co.  U.  S.  Coast  Artillery  was  shot  at  100  yards  range  by  the  U.  S.  Army 
pointed,  Springfield  rifle,  full-jacketed  bullet.  A  clean  dressing  and  immobilization  were  em- 
ployed at  once.  No  infection''_ensued.  Slight  displacement  of  fragments,  with  1  inch  shortening. 
Limb  is  strong  and  serviceable.  A  slight  limp  renders  patient  unfit  for  military  service.  Dis- 
charged on  S.  C.  D.,  at  U.  S.  A.  Lettermann  General  Hospital,  Nov.  13,  1911.  Fig.  147  shows  femur 
immediately  after  injury.  Figs.  148  and  149  give  postero-anterior  and  side  views  of  femur  with  1 
inch  shortening  at  time  of  discharge.  Reported  by  Major  R.  M.  Thornburg,  M.  C,  U.  S.  A.,  from 
Lettermann     General     Hospital. 

of  the  femur  was  amputation  in  all  cases.  Doubtless  the  rule  was 
established  after  mature  experience  in  earlier  times.  It  was  the  com- 
monly accepted  belief  among  surgeons  then  that  all  gunshot  fractures 
of  the  femur  ended  fatally  unless  they  were  treated  by  amputation. 


352 


GUNSHOT   WOUNDS 


The  ever-present  factor  relating  to  sepsis  and  its  complications,  as 
well  as  the  gravity  of  the  lesions  incident  to  the  use  of  the  armament 
of  those  days,  no  doubt  played  a  great  part  in  the  toll  of  deaths,  and 
in  the  reason  for  the  establishment  of  the  radical  treatment  by  amputa- 
tion. However  this  may  be,  in  1848  it  was  pointed  out  by  the  surgeons 
of  the  French  school,  notably  by  Malgaigne,  Velpeau  and  Jobert, 
that  treatment  by  conservation  had  become  preferable  to  treatment 


Fig.    148. 


Fig.  149. 


by  amputation.  Of  4000  inmates  in  the  hotels  des  Invahdes,  Paris,  ^ 
1814-21,  there  were  but  seven  who  had  recovered  after  conservation  for 
gunshots  of  the  femur,  while  from  1847  to  1853  there  were  sixty-three 
inmates  who  had  been  cured  after  conservation,  and  during  the 
same  period  but  twenty-one  who  had  suffered  amputation  for  gunshots 
of  the  femur.  Since  then  the  plan  of  treatment  by  conservation  has 
steadily  gained  in  popular  favor.  Our  Civil  War  affords  statistics  of 
the  greatest  value  upon  the  results  which  just  preceded  the  antiseptic 
era.  Out  of  6576  gunshot  fractures  3467  were  treated  by  conserva- 
tion. For  the  latter  the  mortality  for  fractures  of  the  upper  third 
^  Delorme,  Op.  cit. 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     353 

was  46  per  cent.;  the  middle  third  40  per  cent.;  the  lower  third  38.2 
per  cent.,  while  the  mortality  following  amputation  was  for  the  upper 
third  73.6  per  cent.;  for  the  middle  third  53.3  per  cent,  and  for  the 
lower  third  45  per  cent. 

The  conservative  treatment  of  gunshot  fracture  of  the  femur  at 
the  present  time  is  very  much  the  same  as  that  already  referred  to  in 
the  case  of  the  other  long  bones.  Rigid  antisepsis  must  be  practised 
in  all  the  details  attending  exploration.  The  latter  is  generally  done 
by  enlarging  the  wound  of  exit.  All  loose  fragments  as  determined 
by  digital  examination  should  be  extracted,  and  those  which  still 
adhere  to  periosteum  or  soft  parts  should  be  replaced  as  near  as  possible 
to  their  normal  position.  After  bleeding  has  been  properly  checked 
the  wound  should  be  irrigated  vnth.  a  weak  antiseptic  solution,  proper 
drainage  should  be  employed  for  the  next  twenty-four  to  forty-eight 
hours,  and  the  limb  should  then  be  dressed  with  a  clean  dressing  and 
immobihzed.  The  latter  is  most  effective  when  it  includes  the  pelvis, 
hip  and  foot.  When  transport  is  inevitable  immediately  after  the 
injury,  nothing  takes  the  place  of  a  well  fitting  plaster-of-Paris  cast 
with  Tvdndow  space  opposite  the  wounds.  This  has  some  objections, 
however.  The  cast  needs  watchful  care  lest  the  bandage  should 
constrict  and  cause  unnecessary  suffering.  In  the  absence  of  plaster 
of  Paris,  splints  of  ^\'ire  netting  or  a  Hodgen  splint  which  tends  to 
obviate  undue  cUsplacement  of  the  upper  and  lower  fragments  is  very 
popular  wdth  mihtary  surgeons.  Sand  bags  and  a  long  outside  with  a 
short  inside  sphnt  and  a  Buck's  extension  will  answer  in  the  absence 
of  something  better.  The  great  problem  is  to  keep  the  limb  immobile 
and  to  avoid  sepsis.  The  first  is  met  most  effectually  ^vith  a  plaster 
cast,  and  the  latter  will  require  the  unremitting  attention  of  the  surgeon. 
In  spite  of  their  well  directed  efforts  the  British  surgeons  noted  101 
septic  cases  out  of  170  gunshots  of  the  femur  in  South  Africa.  Out  of 
twenty-nine  deaths,  twenty-six  or  89.6  per  cent,  died  of  sepsis. 

Excision. — Excision  of  the  femur  for  gunshot  fracture  never  was 
a  popular  method  of  treatment  and,  like  excision  of  the  humerus,  it 
is  no  longer  advocated  by  military  surgeons.  It  proved  to  be  a  very 
fatal  procedure  in  our  Civil  War.  Otis  records  175  excisions  of  the 
femur  for  gunshot  fracture.  Ninety-one  of  these  were  done  in  the 
primary  stage  with  a  mortality  of  76.4  per  cent.  Thirty-eight  cases 
in  the  intermediate  stage  with  a  mortality  of  81.2  per  cent.;  and  eigh- 
teen in  the  secondary  stage  with  a  mortality  of  16.6  per  cent.  All 
the  cases  for  which  primary  excisions  were  once  resorted  to  are  now 


354  GUNSHOT    WOUNDS 

amenable  to  treatment  by  conservation.  The  only  possible  excuse 
for  exsecting  part  of  a  fragment  now  is  found  in  cases  where  the  jagged 
end  of  a  bone  is  uncovered  by  periosteum.  This  should  be  rounded  off 
with  a  rongeur,  otherwise  the  fragments  which  still  adhere  should  be 
replaced,  as  already  recommended,  as  far  as  possible  to  their  normal 
position,  and  the  case  treated  conservatively. 

Amputation. — At  the  same  time  that  conservation  is  the  rule  of 
treatment  for  gunshot  fracture  under  modern  conditions,  there  are  cases 
in  which  primary  amputation  is  the  only  measure  to  be  resorted  to. 
It  is  absolutely  indicated  (1)  when  a  limb  has  been  entirely  or  partly 
torn  away  by  a  large  projectile  or  shell  fragment;  (2)  in  comminuted 
fracture  with  great  destruction  of  soft  parts  common  to  wounds  from 
large  shell  fragments;  or  (3)  in  comminuted  fractures  attended  with  de- 
struction of  the  femoral  vessels  should  the  patient  live  long  enough  to 
reach  hospital  care,  and  again  (4)  in  comminuted  fractures  with  destruc- 
tion of  soft  parts  complicated  by  destruction  of  the  great  sciatic  nerve 
high  up,  all  require  amputation.  In  cases  where  there  is  doubt,  the 
environments  often  decide  in  favor  of  amputation  to  the  exclusion  of 
conservation.  The  crowded  condition  of  the  field  hospitals,  and  the 
lack  of  a  sufficient  force  of  trained  assistants  to  properly  safeguard  the 
wounded  against  infection  are  conditions  that  are  apt  to  compel  ampu- 
tation in  military  practice  at  times.  Enforced  transport  is  harmful  to 
all  kinds  of  fractures,  it  is  prone  to  bring  on  or  to  aggravate  existing 
infection  and  this  is  especially  true  of  gunshots  of  the  femur.  When- 
ever possible  these  fractures  should  not  be  moved  for  a  month  or  six 
weeks. 

When  the  thigh  is  torn  away  by  a  large  shell  fragment,  bleeding 
vessels  should  be  tied,  the  skin  and  soft  parts  should  be  disinfected  and 
dressed  antiseptically  pending  the  disappearance  of  shock,  which  is 
generally  present  in  all  such  cases.  When  reaction  has  set  in,  part  of 
the  femur  should  be  removed  through  a  longitudinal  incision  on  the 
outside  of  the  thigh  and  the  soft  parts  trimmed  and  cleansed,  the 
vessels  should  be  tied,  and  the  end  of  the  bone  properly  covered. 
This  tentative  method  of  dealing  with  cases  when  the  thigh  is  torn 
away  becomes  more  imperative  as  the  site  of  the  injury  nears  the  upper 
end  of  the  femur.  If  a  better  stump  is  desired  later,  it  can  be  obtained 
by  performing  a  new  amputation. 

We  had  132  gunshot  fractures  of  the  femur  in  the  Spanish-American 
War  and  the  British  Army  in  South  Africa  had  170  cases.    If  we  place 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     355 


the  two  groups  together  for  comparison  as  to  death  rate  after  amputa- 
tion we  find  the  following : 

AMPUTATIOX    OF   THIGH    FOR    GUNSHOTS    IN    THE    SPANISH- 
AMERICAN  AND  BOER  WARS 


Position 

No 

.  cases 

Died 

Death  rate 

Upper  third 

Middle  third 

Lower  third 

27 
21 
11                  j 

14 
9 
3 

51.8 
46.6 
27.2 

Totals 

59 

26 

42.5 

Besides  the  cases  given  in  the  foregoing  table  the  British  had 
thirteen  amputations  at  the  hip  for  gunshot  fracture  of  the  femur  with 
eight  deaths,  a  mortality  of  61.5  per  cent,  and  six  amputations  of  the 
thigh,  the  point  of  amputation  "not  specified,"  with  three  deaths,  a 
mortality  of  50  per  cent.  If  we  add  these  to  the  foregoing  table  we 
have  a  total  of  seventy-eight  amputations  for  gunshot  of  the  femur  with 
thirty-seven  deaths  or  a  mortality  of  47.4  per  cent.  There  was  a 
considerable  number  of  the  fractures  due  to  shell  wounds  in  South 
Africa  and  but  two  cases  in  the  Spanish-American  War  so  that  by 
grouping  the  cases  from  the  two  wars  we  have  the  results  as  far  as 
the  character  of  the  lesions  is  concerned  nearer  the  condition  which 
must  obtain  in  the  wars  of  the  present. 

The  mortality  after  amputation  of  the  thigh  for  gunshot  fracture 
in  the  wars  of  to-day  is  higher  than  one  would  expect  from  the  favor- 
able results  that  attend  other  operative  procedures  under  modern 
conditions.  The  mortality  in  the  preantiseptic  era  was  always  very 
high.  In  the  Crimean  War  out  of  1666  amputations  of  the  thigh  there 
were  1532  deaths,  a  mortality  of  91  per  cent.;  in  our  Civil  War  out  of 
6229  amputations  of  the  femur,  of  which  2900  were  performed  for 
gunshots  of  the  femur  proper,  there  were  3310  deaths  or  a  mortality 
of  53.8  per  cent.;  and  of  9017  amputations  of  the  thigh  as  a  result  of 
gunshot  collected  by  Otis  in  the  important  wars,  between  1689  and 
1876,  there  were  7049  deaths,  a  mortality  rate  of  83.2  per  cent.  It  is 
safe  to  state  that  the  vast  majority  of  fatal  cases  in  the  preantiseptic 
era  died  as  a  result  of  sepsis.  The  curse  of  the  latter  which  pursued 
the  older  surgeons  seems  still  to  cling  to  the  practice  of  military 
surgery.     Thus  Hickson  states  that  of  the  170  cases  of  fracture  of  the 


356  GUNSHOT    WOUNDS 

femur  in  the  Anglo-Boer  War  amputation  was  resorted  to  in  forty-five 
cases  with  a  death  rate  of  53.3  per  cent.,  and  that  the  indication  for 
amputation  was  septic  infection  in  all  of  the  cases  except  three,  which 
required  amputation  as  a  result  of  severe  primary  hemorrhage.  Of 
the  thirty-one  amputations  of  the  thigh  in  our  records  for  the  Spanish- 
American  War  the  indication  for  operation  as  far  as  we  are  able  to 
learn  was  septic  infection  in  the  large  majority.  These  facts  are 
touched  upon,  not  with  a  view  to  criticize  adversely  the  practice  of 
the  field  surgeons,  but  to  lay  renewed  stress  upon  the  necessity  for  the 
exercise  of  the  greatest  care  in  the  management  of  gunshots  of  the 
femur  from  the  time  of  the  first  dressing.  In  cases  which  exhibit 
doubt  as  to  the  necessity  for  exploration,  the  decision  should  always 
be  in  favor  of  operation.  Enlarging  the  wound  of  exit,  removal  of 
loose  fragments,  thorough  irrigation  of  the  foyer  of  fracture  with  a 
weak  antiseptic  solution  and  the  establishment  of  good  drainage,  will 
keep  sepsis  in  abeyance  and  check  it  ultimately,  and  when  this  is 
done  the  principal  reason  for  amputation  with  its  high  mortality  will 
have  been  set  aside. 

Gunshot  Fractures  of  the  Leg. — ^There  were  9171  injuries  of  the 
bones  of  the  leg  in  our  Civil  War,  of  which  183  are  ascribed  to  shot 
contusions,  while  the  remainder  were  shot  fractures.  The  statistics 
of  our  war  hospitals  at  that  time  show  that  about  one-third  of  the 
fractures  of  the  long  bones  are  found  in  the  leg,  and  that  they  form 
about  3  per  cent,  of  war  wounds  by  gunshot. 

The  tibia  and  fibula  are  harder  than  the  long  bones  generally, 
and  on  account  of  their  exposed  position  in  the  lower  part  of  the  leg 
the  fractures  in  this  location  exhibit  a  high  degree  of  comminution, 
amounting  to  explosive  effects  in  a  considerable  proportion  of  the  cases. 
The  latter,  though  not  specially  dangerous  to  life,  call  for  a  large  per- 
centage of  amputations. 

Contusion  of  the  bones  of  the  leg  was  more  frequent  with  the  use  of 
the  lead  bullets  of  the  old  armament.  They  are  so  far  but  seldom 
referred  to  in  the  wars  of  the  present.  Still,  the  exposed  position  of  the 
tibia  and  fibula  will  render  them  liable  to  this  form  of  lesion.  Otis 
found  that  the  internal  surface  of  the  tibia  is  more  liable  to  this  accident 
than  the  other  surfaces  of  the  bone.  Out  of  175  contusions  treated  by 
conservation  he  found  the  lesion  located  on  the  internal  surface  in  132. 
Contusion  of  the  fibula  is  less  serious  than  that  of  the  tibia. 

Treatment  of  Contusion. — The  rule  of  treatment  is  the  same  as 
that  laid  down  for  contusion  of  bone  from  gunshot  already  referred 


GUNSHOT   INJURIES    OF   THE    DIAPHYSES    OF   THE    LONG   BONES     357 

to,  and  this  consists  largely  in  employing  means  to  prevent  sepsis. 
Projectiles  lodged  adjacent  to  bone  should  be  removed  as  soon  as 
located,  and  the  limb  should  be  immobihzed  from  the  beginning. 
With  the  first  evidence  of  inflammatory  disturbance  in  the  bone 
imphcated,  free  incisions  should  be  made  down  to,  and  including  the 
periosteum,  and  when  the  history  of  the  case  calls  for  it,  the  compact 
substance  of  the  bone  should  be  trephined  down  to  the  medullary 
canal,  and  this  mode  of  drainage  should  be  repeated  in  the  continuity 
of  the  bone  at  such  points  as  may  be  deemed  necessary.  Good  drainage 
and  thorough  irrigation  with  antiseptic  solutions  will  usually  arrest 
the  bone  lesion,  and  when  they  fail  amputation  is  called  for.  Otis 
refers  to  183  cases  of  gunshot  contusions  of  the  bones  of  the  leg  in  our 
Civil  War,  of  which  165  were  treated  by  conservation  with  fifteen 
deaths;  eight  were  amputated  in  the  leg  with  four  deaths;  one  amputa- 
tion was  done  through  the  knee-joint  with  fatal  result  and  nine  suffered 
amputation  in  the  thigh  with  six  deaths.  We  have  detailed  the 
results  in  these  cases  of  contusion  to  call  special  attention  to  the 
dangerous  nature  of  such  lesions.  We  have  reason  to  believe  that 
under  our  modern  methods  of  wound  treatment  the  sacrifice  of  life 
and  limb  mentioned  can  now  be  materially  lessened. 

Treatment  of  Gunshot  Fractures  of  the  Tibia  and  Fibula. — The 
treatment  of  gunshots  of  the  diaphyses  of  the  bones  of  the  leg  will  be 
dealt  with  under  (1)  treatment  by  conservation,  (2)  excision,  (3) 
primary  amputation  and  (4)  secondary  amputation. 

(1)  Treatment  by  Conservation. — Out  of  146  gunshot  fractures  of 
the  bones  of  the  leg  treated  by  conservation  in  the  Spanish-American 
War  we  had  six  deaths  or  a  mortahty  of  4.1  per  cent.,  while  the 
mortality  after  amputation  in  fifteen  cases  was  13.3  per  cent. 

The  British  returns  from  the  South  African  War  give  account 
of  137  cases  as  follows:  Fracture  of  the  tibia  and  fibula,  48;  fracture 
of  the  tibia  alone,  72;  fracture  of  the  fibula  alone,  17.  The  great 
difficulty  in  treating  gunshot  fracture  of  the  leg  is  the  almost  uniform 
presence  of  infection.  The  British  returns  which  contain  accurate 
records  on  this  point  show  that  thirty-eight  cases  out  of  forty-eight 
fractures  of  the  tibia  and  fibula  together  were  septic.  Although  the 
number  of  septic  cases  is  not  available  in  our  records,  we  have  reason 
to  believe  that  the  percentage  of  septic  cases  was  high.  The  shoes, 
boots,  leggings  and  clothing  surrounding  the  legs  of  soldiers  in  campaign 
are  necessarily  soiled  unduly  with  dirt  from  the  surface  of  the  earth, 
and  a  gunshot  through  the  leather  and  fabrics  mentioned  contaminates 


358  GUNSHOT    WOUNDS 

the  wound  with  septic  microbes  which  find  lodgment  on  shreds  of 
clothing,  pieces  of  leather,  particles  of  skin,  etc.,  which  are  carried  into 
the  wound  by  the  bullet.  Wounds  in  war  do  not  receive  the  prompt 
attention  that  is  generally  bestowed  upon  them  in  fixed  hospitals. 
Men  lie  where  they  are  shot  for  a  long  time  unattended.  In  a  great 
battle,  it  may  be  days  before  all  the  wounds  are  properly  dressed.  Delay 
in  gunshot  fractures,  where  infection  is  unavoidable  as  it  is  in  wounds 
of  the  leg,  means  a  rapid  spread  of  the  infection,  and  unless  medi- 
cal officers  have  the  time  and  opportunity  to  grant  the  unremitting 
care  and  attention  necessary  to  control  the  inflammatory  conditions 
that  already  exist,  there  will  be  troublesome  complications  to  combat 
later.  A  clean  dressing  and  immobilization  are  the  first  indications 
in  gunshot  fractures  of  the  leg.  This  is  about  all  that  can  be  done  at  a 
first-aid  station.  The  dearth  of  water  that  generally  obtains  on  the 
line  has  made  this  class  of  injuries  hitherto  difficult  to  deal  with.  We 
used  to  apply  a  clean  dressing  to  a  dirty  field  and  trust  the  case  to 
nature  until  a  more  favorable  opportunity.  Now  we  have  in  tincture 
of  iodine  or  one  of  the  iodine  preparations  already  mentioned 
a  valuable  method  of  sterilizing  the  surface  surrounding  the  wound,  so 
that  any  additional  infection  from  this  source  is  preventable.  At  the 
earliest  opportunity,  those  cases  which  require  exploration  should 
receive  prompt  attention.  The  wound  of  exit  should  be  enlarged, 
and  all  loose  fragments  should  be  removed.  Bleeding  vessels  should 
be  tied,  and  when  either  the  anterior  or  posterior  tibial  arteries  are 
wounded  the  condition  of  its  corresponding  tibial  nerve  should  be 
investigated,  and  when  cut  or  lacerated  it  should  be  sutured.  The 
bone  splinters  that  remain  attached  to  periosteum  or  soft  parts  should 
be  put  back  in  their  normal  position  or  as  nearly  so  as  possible; 
drainage  should  be  employed;  the  wounds  thoroughly  irrigated  with 
a  weak  antiseptic  solution,  dressed  in  the  usual  manner  and  the  limb 
immobilized.  A  box  splint  or  any  of  the  methods  generally  used  will 
answer  at  first;  and  later,  nothing  is  better  than  a  plaster-of-Paris 
splint.  When  the  seat  of  fracture  is  near  the  knee-joint,  the  immo- 
bilizing apparatus  should  invariably  include  the  latter. 

The  following  case  exhibits  the  excellent  results  attainable  under 
modern  conditions:  Captain  James  H.  McC,  1st  U.  S.  Vol.  Cavalry 
(Rough  Riders),  was  shot  at  the  battle  of  Guacimus  during  the 
advance  on  Santiago,  June  25,  by  a  Spanish  Mauser  bullet.  The 
bullet  entered  posteriorly  and  to  the  tibial  side  of  the  left  leg  5  1/2 
inches  above  the  internal  malleolus.     It  smashed  the  tibia  at  this 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     359 


point  badly  and  fractured  the  fibula.  There  were  three  small  wounds 
of  exit  on  the  anterior  surface  of  the  leg  just  below  the  level  of  the 
wound  of  entrance.  The  wound  was  at  once  dressed  with  a  field 
dressing.  At  noon  the  next  day  the  writer  assisted  in  operating  upon 
the  case  on  the  hospital  ship  Olivette.  While  the  patient  was  under 
ether  we  found  the  area  of  fracture  in  the  tibia  marked  by  the  presence 
of   a   number   of   small   pieces   of   loose   bone   near  the   wounds  of 


Fig.   150. — Radiograms    showing    postero-anterior  and  side  views  in  the  case  of 
Captain  James  H.   McC. 

exit.  The  Mauser  bullet  had  separated  from  its  jacket  and  a  number 
of  pieces  of  the  core  and  envelope  were  also  removed.  The  wound 
was  thoroughly  irrigated  with  a  1-2000  bichloride  of  mercury  solution 
and  then  immobilized.  In  March,  191.3 — nearly  fifteen  years  after 
the  occurrence — the  writer  was  able  to  secure  a  skiagram  of  Captain 
McC.'s  leg.  There  is  no  deformity  in  the  fibula,  and  but  Httle  de- 
formity in  the  tibia.  Particles  of  lead  from  the  core  of  the  bullet  are 
still  embedded  in  the  tissues.  There  is  3/4-inch  shortening  and  some 
limitation  of  motion  in  the  ankle  as  a  result  of  injury  to  the  tendo 
achilles  (Fig.  150). 

24 


360 


GUNSHOT   WOUNDS 


Without  the  prompt  and  radical  treatment  that  was  practised  in 
this  case,  there  would  have  been  long-continued  inflammation  of  the 
surrounding  tissues,  and  all  the  bone  lesions  that  are  common  to  such 
injuries. 


Fig.  151.  Fig.  152. 

Fig.  151. — Photograph  in  case  of  Pvt.  D.  C.  S.,  Co.  "E,"  20th  Mass.  Lower-halves  bones  leg 
six  months  after  injury.  Tibia  fractured  by  musket  ball.  Suppuration  continued  till  amputation 
of  limb  six  months  later.     Civil  War  specimen.     No.  861  A.  M.  M.  , 

Fig.  152.— Photograph  in  case  of  W.  A.,  Pvt.  Co.  "L,"  8th  U.S.  Inf.  Gun-shot  fracture  re- 
ceived in  action  in  Philippines,  Dec,  1906.  Nature  of  weapon  unknown.  Amputation  Oct.,  1908. 
Photograph  represents  femur  after  amputation,  it  shows  the  later  bone  lesions  that  result  from 
failure  to  promptly  remove  loose  fragments  from  a  comminuted  fracture,  a  common  condition  in 
Civil  War  days.  Army  Med.  School  collection.  From  X-ray  Laboratory,  Lettermann  Genl. 
Hospital. 


We  have  selected  two  specimens  from  the  Army  Medical  Museum 
to  illustrate  the  ulterior  effects  of  the  old-time  practice  in  bone  lesions 


GUNSHOT    INJURIES    OF    THE    DIAPHYSES    OF    THE    LONG   BONES     361 


of  gunshot  wounds  when  expectancy  and  conservation  were  restricted 
largely  to  the  ejfforts  of  nature  (Figs.  151,  152  and  153). 

(2)  Excision  of  the  bones  of  the  leg  in  their  continuity  is  not  a 
safe  surgical  precedure.  It  is  sometimes  done  in  a  case  showing  great 
loss  of  substance  in  the  tibia  by  resecting  the  fibula  to  correspond  to 
the  length  of  the  injured  tibia.  In 
such  a  case  the  ends  of  the  bones 
are  to  be  wired.  The  success  of 
such  an  operation  depends  on  rigid 
sepsis,  a  condition  that  can  seldom 
be  assured  in  field  practice. 

(3)  Primary  amputation  of  the 
leg  is  only  practised  now  for  extreme 
destruction  of  the  soft  parts  with 
fracture,  or  when  a  limb  has  been 
carried  away,  lesions  that  are  com- 
mon to  impact  from  large  projec- 
tiles or  their  fragments.  Primary 
amputation  as  a  result  of  gunshot 
fracture  from  the  projectiles  of  hand 
weapons  will  be  seldom  required. 
A  comminuted  fracture  of  both 
bones  with  destruction  of  both  tibial 
arteries  would  constitute  a  cause 
for  amputation,  but  such  an  injury 
is  seldom  seen  from  the  effects  of 
hand  weapons  except  in  the  case  of 
rifle  shots  delivered  at  close  range 
exhibiting  explosive  effects,  or  as  a 
result  of  shot  from  a  shot  gun  de- 
livered at  contact  or  thereabouts. 
Modern  methods  of  treatment  have 
materially  modified  military  prac- 
tice concerning  amputation  of  the 
leg.  After  the  battle  of  Waterloo,  Thompson  recommended  amputa- 
tion (1)  when  a  ball  had  fractured  both  bones  of  the  leg;  (2)  for  gun- 
shot fracture  near  the  knee  or  ankle  with  joint  involvement;  (3) 
when  a  ball  was  deeply  lodged  in  the  tibia;  and  (4)  for  fracture  of 
the  tibia  with  injury  to  the  blood  supply.  In  our  Civil  War  the 
mortality  for  5452  amputations  of  the  leg  was  32.9  per  cent.,  while  the 


Fig.  153. — Skiagram  from  case  of  W.  A. 
Leech,  Co.  "I,"  3rd  Wis.  Vol.  Inf.,  shot 
during  Civil  War  1861-65.  Missile  not 
stated.  Recovery  took  place  after  much 
suppuration.  Skiagram  taken  in  1911.  A. 
M.    School   collection. 


362  GUNSHOT   WOUNDS 

mortality  for  3938  cases  treated  without  operative  interference  was 
13.8  per  cent. 

Improvement  as  a  result  of  conservative  treatment  had  become  evi- 
dent even  in  the  days  of  the  Civil  War,  since  Otis  shows  in  a  tabular 
statement,  in  which  there  appears  2989  cases  from  the  time  of  the  Thirty 
Years'  War  to  and  including  the  Russo-Turkish  War  of  1876-77,  which 
has  a  mortality  rate  of  18.5  per  cent,  or  4.7  per  cent,  greater  than  the 
results  of  our  Civil  War.  But  the  remote  and  ulterior  effects  of  con- 
servative treatment  as  practised  at  that  time  should  not  be  forgotten. 
As  late  as  1881  the  Reports  of  the  Pension  Examiners  ''  are  replete  with 
accounts  of  extensive  caries  and  necrosis  with  continued  discharge, 
enlargement  of  the  limb,  irritable  ulcers,  overlapping  with  projection 
of  fractured  ends,  outward  or  inward  curvature,  ankylosis  of  the 
knee  or  ankle  or  both,  contraction  of  toes,  outward  turning  of  foot 
giving  the  ankle  the  appearance  of  being  dislocated,  extensive  and 
adherent  cicatrices,  atrophy  and  weakness,  and  inability  to  sustain  the 
weight  of  the  body"  (Otis). 

(4)  Secondary  Amputation. — Sepsis  and  the  complications  to  which 
it  leads  are  the  causes  of  secondary  amputation.  Secondary  amputa- 
tions as  compared  to  primary  amputations  constitute  the  bulk  of  the 
amputations  in  recent  wars.  In  the  days  of  the  Civil  War  the  term 
intermediary  amputation  was  employed  and  it  had  reference  to  ampu- 
tations performed  soon  after  the  onset  of  acute  inflammatory  mani- 
festations. Under  modern  methods  of  treatment  we  combat  cases 
showing  active  indications  of  sepsis  and  defer  amputation  if  necessary 
to  a  time  when  efforts  at  conservation  have  entirely  failed,  so  that  our 
secondary  cases  appear  proportionally  larger  in  number  than  those  in 
the  American  Civil  War.  The  following  are  the  number  of  amputa- 
tions of  the  leg  at  different  periods  and  the  mortality  rate  recorded 
by  Otis: 


Amputations 

No.  of 
recoveries 

No.  of 
deaths 

Per  cent. 

Primary 3392 

Intermediate 1046 

Secondary 444 

2307 

682 
327 

1032 
364 

117 

30.9 

34.75 

26.3 

Totals 4882 

1 

3316 

1513 

30.98 

GUNSHOT   INJURIES    OF   THE    DIAPHYSES    OF   THE   LONG   BONES     363 

If  we  compare  the  total  number  of  amputations  of  the  leg  and  their 
death  rate  from  the  Government  returns  for  the  Spanish-American 
and  Boer  Wars  we  find  as  follows: 


War 

Cases  operated  on 

Died 

Death  rate 

Spanish-American 

Anglo-Boer 

15 
32 

00  to 

13 . 3  per  cent. 
25.2  per  cent. 

Totals 

47 

10 

21.2  per  cent 

The  records  show  that  nearly  every  one  of  the  amputations  in  the 
last  two  wars  was  done  as  a  result  of  sepsis.  In  other  words  they 
represent  the  class  that  would  have  figured  under  intermediate  and 
secondary  amputations  in  the  Civil  War.  If  we  add  these  two  to- 
gether in  Otis'  table  we  find  a  total  of  1490  intermediary  and  secondary 
amputations  with  a  total  of  481  deaths  or  a  mortality  rate  of  32.2  per 
cent,  as  compared  to  21  per  cent,  for  the  Spanish-American  and 
Anglo-Boer  Wars.  This  gives  11.2  per  cent,  in  favor  of  modern 
armament  and  antiseptic  methods  of  treatment.  The  mortality  after 
amputations  of  the  leg  in  the  Spanish-American  and  Anglo-Boer 
wars  is  entirely  too  high.  Our  object  in  making  the  foregoing  com- 
parisons is  to  call  renewed  attention  to  the  necessity  of  exercising 
greater  care  in  batthng  against  sepsis  in  war.  Gunshot  fractures  of 
the  long  bones  should  be  among  the  very  first  to  receive  the  attention 
of  surgeons  and  this  should  be  carried  out  on  the  lines  laid  down 
under  conservation  in  the  large  majority  of  the  cases. 

The  kind  of  amputation  to  be  performed  will  depend  upon  the 
lesion  to  the  soft  parts.  Speaking  generally,  as  much  of  the  limb 
should  be  retained  as  the  injury  will  permit.  When  amputation  is 
required  for  osteomyelitis  the  point  of  election  is  through  the  knee- 
joint,  or  the  lower  third  of  the  femur. 

In  dealing  with  the  results  of  gunshot  fractures  in  this  chapter  as 
far  as  they  relate  to  the  wars  of  the  present,  we  have  confined  ourselves 
largely  to  the  Government  reports  of  the  Spanish-American  and 
Boer  Wars.  Although  the  number  of  cases  is  not  large,  we  believe 
that  when  the  Government  reports  of  larger  wars  like  the  Russo- 
Japanese  and  Turko-Balkan  Wars  are  available  the  results  in  the 


364  GUNSHOT   WOUNDS 

United  States  and  English  reports  will  very  nearly  represent  the 
conditions  in  more  recent  wars.  We  have  never  laid  much  stress 
upon  the  reports  of  isolated  observers  from  any  of  the  later  wars, 
because  the  general  results  of  war  wounds  can  only  be  estimated  after 
due  consideration  of  the  sum  total  of  wounds  received,  and  for  some 
time  after  cessation  of  hostilities. 

GUNSHOT  WOUNDS  OF  THE  FOOT 

In  our  Civil  War  Otis  records  5832  gunshot  fractures  of  the  foot 
and  11,369  fractures  of  the  bones  of  the  hand.  The  bones  of  the  foot 
suffered  one-half  as  often  as  those  of  the  hand.  It  is  safe  to  predict 
that  this  proportion  will  be  much  less  hereafter.  While  fighting  under 
cover  in  modern  tactics,  the  foot  is  one  of  the  least  exposed  parts  of 
the  body,  while  the  hand  is  exposed  as  much  now  as  formerly. 

Infection  is  prone  to  occur  in  gunshot  wounds  of  the  foot  in  the 
military  service  especially.  The  opportunity  to  dress  the  cases  in 
active  campaign  is  often  delayed  so  that  dirt  from  the  shoes,  or  boots, 
and  stockings  driven  in  by  the  bullet  has  infected  the  wound  before 
the  application  of  a  suitable  dressing  has  been  made.  Once  inflam- 
mation has  gained  access  to  the  wound,  it  is  difficult  successfully  to 
combat  its  spread  because  of  the  intimate  relation  between  the  bones 
and  joints  of  the  tarsus  and  metatarsus.  Fractured  bones,  when 
exposed  to  inflammation  in  such  inaccessible  regions,  are  apt  to  undergo 
necrosis  and  exfoliation.  The  inflammatory  process  is  often  prolonged 
in  spite  of  the  active  measures  of  treatment  that  are  instituted.  The 
effects  in  the  end  are  toward  ankylosis  of  the  ankle  and  adjacent 
joints,  loss  of  the  arch,  and  utility  of  the  foot  for  walking. 

The  mortality  of  gunshot  fractures  of  the  foot  in  our  Civil  War, 
largely  as  a  result  of  sepsis,  aggregated  8.3  per  cent.;  and  7.8  per  cent, 
in  the  Franco-German  War  of  1870  and  '71. 

Out  of  158  cases  of  gunshot  fractures  of  the  metatarsus  and  toes 
reported  by  the  Surgeon-General,  U.  S.  Army,  for  the  years  1898  to 
1900  inclusive,  there  were  but  three  deaths,  and  two  of  these  are 
ascribed  to  other  causes.  Reduced-caliber  bullets  were  responsible 
for  fifty  of  the  cases,  and  two  to  shell  fragments.  One  hundred  and 
eighteen  were  restored  to  duty;  sixteen  were  discharged  for  disability 
and  the  others  were  discharged  by  order,  expiration  of  term  of  service, 
etc. 

In  spite  of  the  efficiency  of  the  modern  treatment  of  gunshot 


GUNSHOT   INJURIES    OF    THE    DIAPHYSES    OF   THE    LONG   BONES     365 


wounds,  Stevenson  reports  fourteen  septic  cases  out  of  thirty-two 
gunshots  of  the  tarsal  and  metatarsal  bones  in  the  Anglo-Boer  War. 
There  were  no  deaths,  twenty-four  were  inflicted  by  rifle  bullets, 
seven    by    shell.     Twelve    cases    exhibited    perforation,    there    was 


Fig.  154.  Fig.   15.5. 

Fig.  154. — Shows  the  result  of  a  transverse  shot  through  metatarsal  bones  of  foot  in  a  soldier  at 
Santiago  by  a  Mauser  bullet.  Radiogram  was  taken  22  months  after  injury.  Callus  formations 
were  painful  in  sole  of  foot  on  walking. 

Fig.  155. — Shows  foot  after  we  had  amputated  two  toes  and  part  of  corresponding  metatarsal 
bones,  Fig.  154.  Radiogram  taken  25  months  after  injury.  Army  Medical  School  collection. 
U.  S.  Soldiers  Home  X-ray  Laboratory.      Dr.  A.  B.  Herrick,   X-rayist. 

grooving  in  five,  and  comminution  in  thirteen.  The  condition  of 
the  foot  was  good  in  five,  and  bad  in  six  cases.  Primary  amputation 
was  performed  in  the  shell  cases,  and  there  were  two  secondary 
amputations  in  the  leg. 


366 


GUNSHOT   WOUNDS 


Treatment. — Conservation  is  to  be  employed  in  the  large  majority 
of  gunshots  of  the  foot.  Primary  amputation  is  indicated  in  nearly 
all  cases  resulting  from  shell  fragments.     The  mode  of  amputation 

will  depend  upon  the  amount  of 
destruction  of  bone  and  soft  parts, 
The  classical  operations  of  Hey, 
Chopart,  or  Sj^me  are  usually 
employed. 

Secondary  excision  may  become 
necessarj^  when  conservation  fails, 
in  which  case  the  removal  of  the 
foyer  of  suppuration  will  have  to  be 
practised.  This  may  include  any 
part  of  the  foot.  Painful  callus  is 
another  cause  for  partial  excision. 
Transverse  shots  across  the  foot  by 
modern  rifle  bullets  are  attended 
with  many  displaced  fragments  and 
resulting  callus,  for  the  relief  of 
which  operative  interference  at  times 
becomes  necessary  (Figs.  154,  155). 
Hemorrhage  from  the  larger 
vessels  traversing  the  sole  of  the 
foot  is  not  an  infrequent  complica- 
tion. Bleeding  from  such  a  source 
is  best  controlled  by  tying  both  ends 
of  the  injured  vessel.  Pressure  is 
uncertain  except  for  hemorrhage 
from  the  smaller  vessels,  and  ligation 
of  the  anterior  and  posterior  tibials 
is  apt  to  end  in  gangrene. 

The  greatest  care  should  be  em- 
ployed in  cleansing  the  wound  and 
the  surface  adjacent  to  it  before  ap- 
plying the  first  dressing.     Explora- 
tion should  be  avoided  except  for  the  removal  of  missiles  or  loose  bone 
fragments.     After  the  application  of  a  sterile  dressing  immobihzation 
should  be  applied. 


Fig.  156. — The  foUomng  case  is  of 
special  interest  to  recruiting  officers.  Pvt. 
Raymond  H.  R.  Co.  "H"  13th  Inf.  A  .22 
cal.  rifle  bullet  lodged  in  metatarsal  bone 
great  toe,  accidentally  inflicted;  detected 
by  X-ray  two  years  after  enlistment.  Was 
admitted  to  sick  report  for  "arthritis  sub- 
acute, metatarso-phalangeal  joint  great  toe.' ' 
Army  Medical  School  collection.  X-ray 
Laboratory,  Fort  Leavenworth,  Kansas. 


CHAPTER  XIII 

Medico-legal  Phases  of  Gunshot  Wounds 

The  medico-legal  phases  of  gunshot  wounds  require  a  consideration 
of  certain  points,  with  definite  answers,  as  far  as  these  are  obtainable 
by  evidence  at  the  time  of  occurrence,  and  such  evidence  as  may  be 
adduced  by  a  knowledge  of  firearms,  projectiles,  explosives,  etc. 
The  behavior  of  the  last  two  on  tissues  and  clothing  at  the  time  of 
discharge  frequently  affords  evidence  of  the  greatest  value.  The 
effects  of  projectiles  and  explosives  on  the  body  involve  many  problems 
that  are  submitted  to  the  mecUcal  \\'itness  for  solution  which  may  be 
discussed  under  the  following  heacUngs: 

1.  Diagnosis  of  a  Wound  Caused  by  Firearms. 

2.  At  What  Distance  was  the  Firearm  Discharged? 

3.  When  was  the  Wound  Infhcted,  Before  or  After  Death? 

4.  Is  the  Wound  Dangerous  to  Life? 

5.  The  Practitioner's  Liability  in  Case  of  Infection. 

6.  How  was  the  Wound  Infhcted? 

7.  Was  it  Accident,  Suicide  or  Homicide? 

8.  Identity  of  the  Individual  by  the  Flash  of  the  Firearm. 

9.  Self-inflicted  Non-fatal  Wounds. 

10.  At  What  Time  was  the  Firearm  Discharged? 

11.  Was  the  Projectile  Jacketed  or  not? 

1.  Diagnosis  of  a  Wound  Caused  by  Firearms. — -The  appearance 
of  a  gunshot  wound  is  at  times  atypical  and  doubt  arises  as  to  whether 
the  injury  was  the  result  of  gunshot.  Doubt  is  reasonable  onlj^  when 
superficial  bruise  or  abrasion  is  found.  A  gunshot  wound  is  marked 
by  a  wound  of  entrance  and  most  generally  by  a  wound  of  exit. 

Wound  of  Entrance. — The  skin  wound  of  entrance  corresponds  to 
the  diameter  of  the  projectile  inflicting  it.  At  times  the  aperture  of 
entrance  appears  smaller  than  the  diameter  of  the  projectile,  but  the 
difference  is  only  apparent  since  the  wound  invariably  admits  a  pro- 
jectile of  like  caliber  to  the  one  which  has  caused  it.  The  smaller 
appearance  is  due  to  shrinking  from  the  elasticity  of  the  skin.  Wounds 
inflicted  in  skin  overlying  bone  or  resistant  aponeurosis  will  show  a 

367 


368  GUNSHOT    WOUNDS 

wound  of  entrance  exceeding  the  size  of  the  bullet.  The  edges  of 
the  wound  may  be  scorched  or  not,  depending  on  the  proximity  of 
the  muzzle  at  the  time  of  discharge  and  to  the  kind  of  powder  used. 
Black  powder  which  liberates  its  gases  by  ignition  causes  burning  and 
tattooing  with  proximal  shots;  the  nitro-cellulose  powders  and  de- 
tonators do  not  cause  burning,  and  tattooing  is  less  marked.  The  lead 
bullets  which  were  formerly  lubricated  left  a  dark  coating  about  the 
edges  of  the  entrance  wound  in  the  skin  which  simulated  the  ap- 
pearance of  burning,  but  close  inspection  in  such  cases  revealed  the 
true  nature  of  the  discoloration.  The  edges  of  the  entrance  wound  are 
more  or  less  inverted,  lacerated,  bruised  and  surrounded  at  times  by 
ecchymosis.  The  wound  of  entrance  contains  bony  sand  in  some 
gunshot  wounds  from  the  reduced-caliber  rifle  when  fracture  of  a 
resistant  bone  has  taken  place  at  the  proximal  ranges.  The  wound  is 
rounded  when  the  piece  is  held  at  some  distance.  When  the  muzzle  is 
held  at  contact  the  skin  is  torn  and  lacerated.  Bleeding  is  slight 
unless  a  vessel  near  the  surface  is  injured,  but  bleeding  is  more  often 
seen  at  the  wound  of  exit.  Direct  impact  causes  a  round  wound  of 
extrance,  while  tangential  shots  show  oval  skin  apertures.  A  wound 
of  entrance  in  skin  overlying  loose  areolar  tissue  like  the  scrotum  may 
appear  much  smaller  than  the  projectile  on  account  of  the  extreme 
elasticity  of  the  skin  in  this  region.  Bullets  from  the  high-power 
reduced-caliber  rifles  often  show  a  mere  slit  in  skin,  which  is  wrinkled 
like  that  of  the  scrotum,  neck  or  knee. 

Wound  of  Exit. — The  exit  aperture  never  exhibits  tattooing, 
burning  or  other  disfigurement  from  the  powder  charge.  It  is  usually 
larger  than  the  wound  of  entrance  and  in  cases  of  bone  lesion  it  may 
exceed  the  size  of  the  projectile  many  times.  It  is  more  irregular  than 
the  wound  of  entrance.  The  edges  of  the  wound  are  everted,  and  sub- 
cutaneous fat  may  protrude  from  it.  In  cases  of  gunshot  fracture  at 
proximal  ranges  by  the  reduced-caliber  rifle,  the  wound  of  exit  may  be 
multiple  from  pieces  of  the  bullet  or  particles  of  bone  having  been 
driven  forth  with  the  bullet  as  secondary  projectiles.  For  reasons  not 
easily  explained  there  are  cases  in  which  the  wounds  of  entrance  and 
exit  are  so  nearly  alike  that  it  is  difficult  to  distinguish  the  one  from  the 
other.  The  wounds  of  entrance  and  exit  of  a  jacketed  bullet  at  proxi- 
mal ranges  are  very  much  alike  when  soft  parts  alone  have  been 
traversed.  Low-velocity  projectiles  composed  of  lead  are  apt  to  be 
deflected  and  many  instances  are  given  of  bullets  following  the 
contour  of  the  body.     The  high-velocity  military  and  sporting  rifles 


MEDICO-LEGAL    PHASES    OF    GUNSHOT    WOUNDS  369 

of  the  present  day  shoot  projectiles  that  travel  in  a  straight  line,  and 
it  is  safe  to  assert  that  the  channel  of  a  bullet  from  these  weapons  is 
marked  by  a  straight  line  drawn  between  the  entrance  and  exit 
wounds  when  the  parts  have  been  placed  in  the  position  which  they 
occupied  when  hit. 

Multiple  wounds  are  common  in  shotgun  injuries,  and  they  give 
valuable  evidence  of  direction  when  but  one  shot  has  been  fired.  As  a 
result  of  superior  velocity'  and  penetration,  multiple  wounds  from  one 
shot  are  common  with  the  present-day  military  and  sporting  rifles  of 
reduced  caliber.  A  man  entered  the  hospital  at  Siboney,  in  the 
Santiago  campaign,  ^^-ith  six  wounds  inflicted  by  one  Mauser  bullet, 
implicating  the  right  shoulder  and  both  breasts.  There  were  a  number 
of  instances  in  which  wounds  of  the  body  were  associated  with  wounds 
of  the  arm  or  forearm,  or  both,  the  latter  being  in  a  state  of  flexion 
at  the  time  of  injury.  Capt 7t  .  Infantry,  re- 
ceived four  wounds  of  the  face  followed  by  no  disfigurement.  The 
projectile,  a  Mauser,  entered  the  right  cheek  below  the  outer  canthus, 
emerged  on  the  nasal  side.  It  next  entered  the  right  side  of  the  nose 
and  emerged  on  the  opposite  side.  Wounds  of  entrance  and  exit  in 
the  upper  thighs  were  several  times  complicated  by  wounds  of  the 
scrotum  or  penis  by  the  same  bullet. 

2.  At  What  Distance  was  the  Firearm  Discharged? — The  cUstance 
between  the  muzzle  of  the  weapon  and  the  point  of  impact  is  one  of 
the  most  frequent  questions  propounded  to  the  medical  witness  in 
courts  of  law  and  it  is  not  always  an  easy  question  to  answer.  The 
appearance  of  powder  grains  buried  in  the  skin  and  the  way  in  which 
they  may  have  penetrated  certain  thicknesses  of  clothing  will  some- 
times indicate  the  approximate  distance  at  which  a  pistol  or  other 
weapon  was  held  when  fired.  Burning  of  the  clothing,  scorching  of 
the  skin,  or  singeing  of  the  hair,  which  is  apt  to  occur  with  the  use  of  the 
old  black  powder,  furnished  invariable  evidence  of  a  shot  at  close 
range  and  it  often  indicates  the  manner  in  which  the  weapon  was  held 
when  fired.  Each  weapon  with  a  definite  charge  of  the  propellant  has 
a  distance  limit  where  deposits  of  powder  grains  will  make  an  im- 
pression upon  the  surface.  The  same  may  be  said  of  the  "powder 
brand"  first  described  by  Dr.  B.  F.  N.  Fish  of  Boston.^  In  experiments 
which  he  made  on  blotting  paper  with  pistols  he  describes  the  powder 
brand  as  follows:  "1  noticed,  in  addition  to  the  smutting  of  the 
paper  by  smoke  and  to  the  marks  of  the  burned  and  unburned  grains 
1  Dr.  B.  F.  N.  Fish,  Boston  Med.  and  Surg.  Journal,  Oct.  2,  1884. 


370  GUNSHOT   WOUNDS 

of  powder  distributed  around  the  bullet  hole,  one  spot  blacker  and  more 
burned  than  the  rest.  I  found  this  was  caused  by  the  flame  of  the 
gases  of  the  burning  powder,  and  by  the  residue  or  ash  of  the  burned 
powder  striking  and  resting  in  this  place.  I  also  noticed  that  this 
burned  and  blackened  spot  held  a  most  constant  position,  directly 
above,  or  above  and  a  little  to  one  side  of  the  bullet  hole."  He 
also  found  that  the  powder  brand  about  the  bullet  hole  invariably 
occurred  on  the  hammer  side  of  the  weapon.  That  is,  if  the  pistol  or 
revolver  was  held  hammer  to  the  left,  the  powder  brand  occurred  on 
the  left  of  the  orifice  made  by  the  bullet.  When  the  weapon  was  held 
with  the  hammer  to  the  right,  the  brand  was  noticed  to  the  right  of 
the  bullet  hole.  When  the  weapon  was  held  with  the  hammer  up  or 
down,  the  brand  was  located  likewise  above  or  below  the  bullet  hole. 
The  explanation  of  the  position  of  the  powder  brand  is  as  follows :  As 
the  weapon,  a  pistol  or  revolver,  is  held  in  the  hand  the  latter  forms 
the  point  of  support  for  the  recoil.  The  point  of  support  is  below 
the  line  of  application  of  the  force  generated  by  the  ignited  powder  and 
on  discharge  the  force  tends  to  make  the  weapon  revolve  about  the 
point  of  support.  The  projectile  is  first  discharged  and  as  the  weapon 
revolves  upward  the  gases  behind  the  ball  follow  the  new  direction 
assumed  by  the  barrel,  and  the  products  of  combustion  are  thus 
delivered  on  the  target  above  the  bullet  hole,  to  one  side,  or  below 
according  to  the  way  in  which  the  hammer  is  held.  If  the  weapon  is 
held  stationary  in  a  vice  when  fired,  the  recoil  does  not  affect  the  direc- 
tion of  the  barrel  and  the  brand  and  tattooing  are  equally  distributed 
about  the  bullet  hole.  When  held  normally  in  the  hand  the  distance 
of  the  brand  from  the  bullet  hole  is  greater  as  the  distance  between  the 
weapon  and  target  increases:  the  angle  made  by  the  barrel  in  its  align- 
ment before  and  after  the  recoil  is  the  same,  but  the  line  on  the  target 
which  subtends  this  angle  will  naturally  increase  with  the  distance 
from  the  point  of  discharge. 

The  appearance  of  the  powder  brand  has  frequently  figured  in 
the  courts.^  When  present,  it  has  afforded  strong  presumptive  evi- 
dence of  suicide  or  homicide. 

The  powder  brand  as  described  is  better  marked  with  the  use  of  the 
old  black  powder  in  pistols  and  revolvers.  We  have  found  that  the 
greater  number  of  powder  marks,  independent!}^  of  the  brand,  was  in- 
variably on  the  hammer  side  of  the  weapon.     This  was  the  case  with 

^  Text-book  of  Legal  Medicine,  etc.,  Peterson  and  Haines,  article  on  Gunshot 
Wounds  by  Dr.  J.  N.  HaU,  W.  B.  Saunders  Co.,  Phil.,  1903. 


MEDICO-LEGAL    PHASES    OF    GUNSHOT    WOUNDS  371 

all  the  specimens  tested  with  the  exceiDtion  of  the  Peyton  powder  when 
shot  out  of  the  military  rifle.  With  this  the  majoritj'  of  the  powder 
grains  appeared  below  the  bullet  hole  when  the  rifle  was  held  in  the 
regular  way.  It  is  possible  that  other  brands  of  powder  "v\dll  act 
likewise,  hence  the  necessity  of  conducting  tests  in  any  given  case. 

Witnesses  in  courts  of  law  often  need  to  know  the  behavior  of  the 
different  explosives  relating  to  the  degree  of  powder  burn  or  tattoo  as 
modified  by  the  distance  of  the  object,  the  size  of  bore  and  length  of 
barrel,  the  amount  and  standard  of  powder,  etc.  The  exhaustive 
experiments  which  we  made  in  1905  may  be  of  assistance  to  future 
experimenters  or  to  those  who  have  occasion  to  seek  information  as 
witnesses.  In  these  experiments  we  tested  the  effects  of  the  more 
common  rifles  and  revolvers  used  in  this  country,  from  which  we 
fired  nearly  all  the  brands  of  black  and  smokeless  powders  in  the 
market  at  that  time.^  Not  infrequently  the  weapon  is  pressed 
against  the  surface  and  held  tightly  by  the  suicide  so  that  the  gases 
and  the  unconsumed  particles  from  the  propellant  are  driven  into  the 
wound  and  the  skin  about  the  wound  of  entrance  will  give  no  evidence 
of  either  brand  or  tattoo.  Unless  the  wound  is  carefully  examined 
the  proximity  of  the  weapon  at  the  time  may  be  overlooked.  The 
wound  in  such  a  case  would  have  the  appearance  of  one  having  been 
inflicted  at  some  distance.  In  the  case  of  Normal  Harris,  which  was 
noted  by  Dr.  C.  S.  White  of  Washington,  the  suicide  held  the 
.38-caliber  pistol  against  the  scalp  behind  the  right  ear  and  fired. 
There  was  no  scorching  of  hair  or  skin  and  no  evidence  of  marks  like 
tattooing  left  by  the  powder  on  the  scalp.  The  suicide  was  found 
dead  in  an  alley  with  a  bullet  hole  in  his  head  and,  to  add  to  the 
complication  in  the  case,  the  weapon  with  which  he  had  inflicted  the 
wound  had  been  taken  by  someone  who  happened  to  be  passing  b}^ 
A  careful  examination  of  the  wound  proper  revealed  particles  of  the 
propellant  and  gave  positive  evidence  of  a  shot  delivered  at  close 
contact. 

The  distance  from  the  weapon  can  sometimes  be  determined  ap- 
proximately by  the  amount  of  penetration  of  the  projectile.  As  a 
rule  the  penetration  is  in  proportion  to  the  velocity.  Close  shots 
penetrate  farther  because  the  bullets  have  a  maximum  velocity. 
Formerly  shots  from  pistols  and  revolvers  seldom  emerged  from  the 
body  when  they  happened  to  collide  with  resistant  bones.     Perfection 

^Experiments  Illustrating  the  Degree  of  Powder  Burn,  etc.,  Journal  Assn. 
Mil.  Surgeons,  Vol.  V,  189.5,  p.  212. 


372  GUNSHOT    WOUNDS 

of  the  more  modern  types  of  revolvers  and  the  automatic  pistols 
which  employ  steel-jacketed  bullets  have  come  into  use  with  an 
initial  velocity  as  high  as  1400  f.s.,  and  the  penetration  of  projectiles 
for  these  weapons  has  been  correspondingly  increased. 

A  lead  bullet  possessed  with  maximum  velocity  will  at  times 
fail  to  penetrate  as  far  as  it  does  when  animated  by  a  lower  velocity. 
Experimenters  often  notice,  for  instance,  that  a  .38-caliber  Colt's 
revolver  bullet  will  perforate  the  skull  of  a  cadaver  at  25  feet,  when  it 
will  fail  to  do  so  at  contact  or  a  foot  or  two  away.  The  explanation 
given  is  this:  a  lead  bullet  traveling  at  a  maximum  velocity  makes 
such  a  sudden  and  violent  impact  that  bone  particles  have  not  time 
to  separate  or  give  way  to  enable  the  ball  to  pass.  The  momentary 
resistance  is  such  that  the  bullet  flattens,  hence  the  deformation 
which  adds  to  the  sectional  area  of  the  bullet,  and  to  this  deformation 
we  ascribe  the  loss  in  penetration.  This  point  came  up  recently  in 
the  case  of  a  young  officer  of  one  of  our  services  when  the  government 
sought  to  show  that  the  officer  came  to  his  death  by  suicide  by  shooting 
when  he  lay  on  the  ground  in  a  struggle  with  other  officers  who  were 
endeavoring  to  restrain  him.  The  muzzle  of  a  .38-caliber  new  service 
Colt's  revolver  was  held  against  the  right  side  of  the  head  and  fired. 
The  ball  entered  the  skull  and  was  lodged  in  the  brain  substance  on  the 
opposite  side  more  or  less  deformed.  The  prosecution  maintained  that 
the  pistol  discharged  at  such  close  range  should  have  sent  the  ball 
through  the  head  and  that  in  all  probability  the  pistol  was  discharged 
at  some  distance  by  someone  else.  There  were  eye  witnesses  to  the 
occurrence,  and  other  evidence  to  confirm  the  charge  of  suicide.  The 
experts  consulted  in  the  case  held  to  the  opinion  that  the  failure  of  the 
ball  to  make  a  complete  perforation  at  such  a  proximal  range  was  due 
to  loss  of  penetration  by  deformation  of  the  bullet  at  the  time  of 
impact.     See  also  case  of  Sergt.  V.,  Figs.  107  and  108,  page  177. 

Wounds  from  Shotguns. — The  penetration  of  pellets  from  shotguns 
varies  naturally  with  the  amount  and  kind  of  charge,  the  distance  of 
the  weapon  and  the  age  of  the  explosives.  In  cases  where  the  court 
desires  information  on  the  degree  of  penetration  of  lead  pellets  or 
projectiles  fired  from  any  weapon,  experiments  to  simulate  the  con- 
ditions at  the  time  of  occurrence  in  a  given  case  should  be  resorted  to, 
either  on  cadavers  or  other  materials. 

Wads  and  wadding  from  shotguns  and  pistols  depending  on  the 
compact  nature  of  the  materials  from  which  they  are  made  have 
caused  fatal  results  at  close  quarters  and  the  charge  of  powder  alone 


MEDICO-LEGAL   PHASES    OF    GUNSHOT    WOUNDS  373 

from  any  weapon  is  at  times  sufficient  to  cause  death  when  discharged 
nearby. 

Projectiles  from  shotguns  may  be  fine  or  coarse  shot,  slugs,  pieces 
of  metal  of  any  kind,  pebbles  or  a  ball.  Unless  the  latter  is  used  the 
effectiveness  of  the  weapon  hardly  exceeds  100  yards,  although 
instances  of  death  beyond  this  distance  from  straj'  pellets  are  recorded. 
The  caliber  of  shotguns  varies  approximately  between  .424  inch  to 
1.052  inches.  The  charge  of  shot  makes  a  close  target  in  accordance 
with  the  degree  of  ''choke."  When  the  choke  is  absent  the  tendency 
to  spread  is  markedly  shown.  The  charge  has  a  single  point  of 
entrance  at  from  1  to  2  feet  depending  upon  the  kind  of  weapon  and 
the  manner  of  loading.  The  wound  of  entrance  when  the  charge  takes 
effect  en  masse  is  never  so  regular  as  it  appears  in  the  case  of  a  bullet. 
Separate  shot  holes  appear  as  the  distance  increases.  The  pellets 
diverge  on  entering,  as  a  rule,  and  this  is  especially  true  if  a  bone  is  hit. 
An  X-raj'  of  the  surrounding  parts  will  generally  indicate  the  amount 
of  spreading.  The  paper-shot  shell  has  been  known  to  separate  from 
its  metallic  head  and  deliver  a  wound  in  a  single  load  as  far  as  200 
yards. 

Evidence  of  Proximity  Afforded  by  Clothing. — Perforation  of  the 
clothing  from  a  projectile  takes  place  verj'  much  in  the  way  that  the 
skin  is  perforated.  The  hole  entering  the  dress  is  round  if  the  velocity 
of  the  bullet  is  high.  A  lower-velocitj^  bullet  pushes  the  clothing 
forward  in  the  shape  of  a  cone,  the  apex  of  which  is  perforated  in  the 
form  of  a  slit  or  triangular  tear.  After  the  perforation  has  taken 
place  the  clothing  assumes  its  original  position  or  part  of  it  may  hang  in 
the  wound.  The  bullet  hole  is  small  in  proportion  to  the  elasticity 
of  the  stuff  penetrated.  Clothing  that  is  stretched  over  the  body  at 
the  time  of  perforation  shows  a  hole  approaching  the  size  of  the 
bullet.  Powder  burn  or  stain  may  occur  from  close  shots.  The  zone 
of  burning  is  round  or  oval  as  the  shot  is  delivered  perpendicularly 
or  at  a  tangent  to  the  cloth.  Unburned  powder  grains  can  be  picked 
out  of  the  cloth  and  with  the  aid  of  a  magnifying-glass  Doctor  J. 
N.  Hall,  of  Denver,  Colorado,  was  able  to  prove  in  a  recent  court  case 
that  the  shooting  took  place  2  or  3  feet  from  the  muzzle  by  demon- 
strating isolated  patches  of  burned  fabric  due  to  ignited  grains  when 
the  distance  had  been  too  great  to  cause  burning  by  the  flame. 

3.  When  was  the  Wound  Inflicted,  Before  or  After  Death? — 
This  question  is  important,  and  it  is  often  asked  to  arrive  at  the  length 
of  time  the  wounded  person  may  have  survived  after  receiving  a  mortal 


374  GUNSHOT   WOUNDS 

wound.  This  can  only  be  arrived  at  by  the  appearance  of  inflamma- 
tion in  Hfe,  which  does  not  set  in  with  anything  like  distinguishing 
features  until  the  lapse  of  ten  to  twelve  hours  in  tissues  generally, 
although  we  know  that  plastic  lymph  is  thrown  out  in  a  wound  of  the 
peritoneum  in  about  three  hours.  The  question  of  the  wound  having 
been  inflicted  before  or  after  death  is  not  easy  to  answer  unless  the 
missile  has  injured  a  vessel  with  resulting  hemorrhage  and  the  forma- 
tion of  coagula.  Gunshot  injury  in  dead  tissue  is  not  followed  by 
hemorrhage  unless  the  projectile  happens  to  wound  a  large  blood- 
vessel and  preferably  a  vein.  Evidence  of  the  movements  the  wounded 
may  have  made  after  receiving  the  injury  will  sometimes  throw  light 
on  the  subject. 

In  a  case  where  several  wounds  may  be  found  on  a  dead  body  it  is 
sometimes  pertinent  to  know  which  of  the  wounds  caused  death.  The 
question  can  only  be  answered  on  general  principles,  taking  into  con- 
sideration the  nature  of  the  wound,  the  parts  injured,  the  amount  of 
injury  to  vital  organs,  etc.  In  a  street  encounter  in  one  of  our  South- 
ern cities  recently  a  man  of  prominence  was  shot  with  an  automatic 
pistol  several  times  in  quick  succession  through  the  body.  Eye 
witnesses  saw  the  wounded  drop  lifeless  to  the  ground  very  suddenly 
during  the  scuffle  that  was  going  on.  The  post-mortem  revealed  several 
wounds  capable  of  causing  death.  In  one  of  these  the  ball  severed 
the  medulla  oblongata.  The  medical  witnesses  testified  that  this 
wound  had  caused  immediate  death,  and  that  it  was  received  when  the 
wounded  was  noticed  to  drop  lifeless  to  the  ground. 

4.  Is  the  Wound  Dangerous  to  Life? — The  danger  to  life  is  de- 
pendent upon  the  anatomical  regions  traversed,  the  local  and  general 
resistance,  and  the  complications  that  are  apt  to  set  in.  The  danger 
in  gunshot  wounds  has  been  lessened  very  much  in  recent  years 
because  of  the  change  in  firearms  and  in  the  projectiles  they  employ, 
and  also  because  of  the  great  advances  in  wound  treatment.  This 
beneficence  has  come  largely  from  the  reduction  of  the  caliber  and 
weight  of  the  bullet  but  more  especially  from  encasing  the  projectile 
in  a  steel  jacket.  The  enveloped  type  of  bullets  does  not  disinte- 
grate as  the  lead  bullets  did,  their  hard  exterior  prevents  deformations 
that  were  once  common  and  which  added  to  the  gravity  of  wounds. 
The  small  frontage  of  the  rifle  bullets  ranging  from  .256  to  .30 
calibers  adds  to  the  humane  features  of  the  injuries  in  the  soft 
parts,  the  epiphyseal  ends  of  bones,  the  lungs  and  liver.  Gunshot 
wounds  of  the  abdomen  in  war  that  were  uniformly  fatal  with  the 


MEDICO-LEGAL    PHASES    OF   GUNSHOT   WOUNDS  375 

old  armament  have  given  under  modern  conditions  a  hope  of  recovery 
in  25  per  cent,  of  the  cases  without  operation  in  wounds  inflicted  by 
the  ogival-headed  reduced-caliber  bullet.  But  the  recent  change  in  the 
shape  of  the  reduced-caliber  mihtary  rifle  bullet  from  an  ogival  head  to  a 
pointed  bullet  has  again  added  very  much  to  the  fatality  of  all  body 
wounds  and  abdominal  wounds  especially.  This  bullet,  as  already 
stated  when  discussing  the  characteristic  features  of  gunshot  wounds 
in  Chapter  II,  has  no  stability.  It  turns  on  encountering  the  least 
resistance  and  when  it  does  so  while  traveling  with  a  rapid  mo- 
mentum its  rending  effects  are  terrific.  The  Turks  used  this  bullet 
in  the  recent  Turko-Balkan  War  with  deadly  effect;  but  few  abdominal 
wounds  lived  to  reach  hospital  care.  The  deadly  slashing  effect  of 
this  bullet  has  made  it  popular  with  sportsmen  and  it  will  no  doubt 
be  very  much  used  in  the  hunt  for  large  game. 

Gunshot  wounds  of  the  abdomen  in  civil  practice  by  the  pro- 
jectiles of  pistols  and  revolvers,  once  so  fatal,  now  give  about  50  per 
cent,  of  recoveries  under  modern  methods  of  treatment.  When  the 
wound  is  inflicted  by  the  smaller  calibers  the  death  rate  is  much  less. 

Notwithstanding  the  beneficence  which  has  resulted  from  the 
change  in  firearms  and  modern  treatment,  a  perforating  gunshot 
wound  of  the  abdomen  from  any  weapon  should  at  all  times  be  con- 
sidered dangerous  to  life.  The  same  may  be  said  of  gunshot  wounds 
of  the  lungs.  It  may  be  stated  as  a  broad  principle  that  gunshot 
wounds  are  dangerous  to  life  in  proportion  to  the  amount  of  tissue 
involvement.  This  is  also  true  of  wounds  from  weapons  that  appear 
to  be  attended  with  little  danger  like  toy-pistol  wounds.  Wounds 
of  this  class  have  been  described  under  toy-pistol  tetanus  and  they  owe 
their  dangerous  nature  to  the  liability  to  infection  from  virulent 
microorganisms  like  the  bacillus  of  tetanus  in  wounds  that  are  marked 
by  the  presence  of  laceration  and  hsematoma. 

Gunshot  wounds  as  a  class  are  more  or  less  contused  and  lacerated, 
and  because  of  this  fact  their  gravity  never  can  be  overlooked.  The 
surgeon  will  have  to  form  his  estimate  of  the  amount  of  danger  in  a 
given  case  bv  his  knowledge  of  regional  anatomy  and  the  importance 
that  the  tissues  traversed  may  bear  to  life,  directly  or  indirectly.  The 
subject  of  wound  infection  plays  a  great  role  in  danger  to  life.  To 
appreciate  this  properly  anyone  who  expects  to  testify  in  a  given  case 
should  read  carefully  the  chapter  on  Infection  of  Gunshot  Wounds. 

5.  The  Practitioner's  Liability  in  Case  of  Infection. — The  knowl- 
edge of  antisepsis  and  the  value  of  cleanliness  are  becoming  so  well 

25 


376  GUNSHOT   WOUNDS 

known  to  the  laity  that  criminal  negligence  with  sepsis  resulting  has 
already  figured  in  the  courts.  Incidentally  the  subject  brings  up  the 
medico-legal  phase  of  septic  bullets.  There  are  two  aspects  of  the 
practitioner's  liability;  he  may  be  prosecuted  criminally  for  negligence 
producing  death,  or  he  may  be  asked  civilly  to  respond  in  damages 
by  the  party  injured  or  by  his  heirs.  For  our  purpose,  however,  the 
rules  of  evidence  and  the  burden  of  proof  may  be  treated  as  sub- 
stantially the  same.  Speaking  thus  with  approximate  accuracy,  if 
the  plaintiff  or  the  prosecution  establishes  (1)  the  existence  of  blood 
poisoning;  (2)  surgical  uncleanliness  i  i  the  use  of  the  instruments  or 
dressings ;  (3)  failure  on  the  part  of  the  operator  to  render  his  hands  or 
those  of  his  assistants  anc  the  field  of  operation  aseptic  in  the  ordinary 
way,  a  prima  facie  case  is  made  against  the  surgeon  which  he  must 
overcome.  Such  culpable  negligence  in  the  light  of  our  present 
knowledge  is  considered  unpardonable  and  yet  in  the  case  of  a  gunshot 
wound  it  would  be  difficult  to  say  that  sepsis  had  resulted  from  neglect 
alone  or  that  a  deadly  poison  like  that  of  tetanus  had  resulted  from  said 
neglect  and  not  as  a  result  of  a  bullet  infected  with  tetanus  spores. 
Ordinarily  the  plaintiff  might  avail  himself  of  evidence  that  (1)  the 
patient's  clothing,  pierced  by  a  bullet,  was  old  and  dirty,  and  hence 
probably  not  aseptic,  and  (2)  that  the  skin  at  the  wound  of  entrance 
and  exit  bore  specific  germs.  Furthermore  two  additional  lines  of 
defence  are  open  to  him,  viz.,  (1)  the  bullet  itself  might  have  been 
septic  when  fired,  and  (2)  by  ricochet,  or  otherwise  while  in  transit, 
it  might  have  become  septic — two  conditions  either  of  which  is  well 
•^dthin  the  bounds  of  possibility.  We  have  shown  already  by  numerous 
experiments  on  animals  shot  into  with  septic  bullets  from  many  dif- 
ferent kinds  of  weapons,  and  at  ranges  up  to  500  yards  with  the  military 
rifle,  that  a  septic  bullet  is  not  rendered  sterile  by  the  act  of  firing,  and 
that  it  can  become  infected  in  ricochet.^ 

6.  How  Was  the  Wound  Inflicted? — This  question  refers  to  the 
position  of  the  individual  when  shot,  (a)  Was  he  standing  or  lying 
down?  (b)  Was  he  running  from  his  assailant  or  advancing?  (c)  In 
what  direction  was  the  weapon  pointed  when  fired?  (d)  Was  it 
fired  from  the  shoulder  or  hand? 

The  above  queries  can  all  be  established  by  eye  witnesses.  In  the 
absence  of  such  testimony  we  have  to  depend  on  such  evidence  as 

^  Are  Projectiles  fron  Portable  Hand  Weapons  Sterilized  by  the  Act  of  Firing? 
Can  a  Septic  Bullet  Infect  a  Gunshot  Wound?  By  Louis  A.  LaGarde,  U.  S.  A. 
Proceedings   Pan-American  Congress,  Vol.  I,  1893. 


MEDICO-LEGAL    PHASES    OF    GUNSHOT    WOUNDS  377 

may  be  afforded  by  the  distinction  of  the  wound  of  entrance  from  the 
wound  of  exit.  In  those  cases  where  the  distinction  is  well  established 
the  position  of  the  victim  when  shot  will  be  apparent.  It  will  show 
whether  the  wound  was  received  when  facing  the  muzzle  or  whether 
his  side  or  back  was  nearest  the  weapon.  The  track  of  the  bullet 
from  the  point  of  entrance  to  the  point  of  exit  or  lodgment  is  usually 
a  straight  line.  When  it  is,  we  here  have  evidence  to  show  how  the 
weapon  was  pointed  when  fired.  When  a  line  between  the  two 
wounds  or  the  wound  of  entrance  to  the  point  of  lodgment  is  curved 
from  a  deflected  bullet  the  value  of  the  evidence  bearing  on  the  way  in 
which  the  gun  was  pointed  is  doubtful.  In  former  times  such  cases 
were  frequent.  The  velocity  of  the  projectiles  was  lower  and  they 
were  easily  deflected  from  their  course  before  and  after  striking  the 
body.  Many  cases  are  cited  in  the  literature  of  gunshot  wounds 
where  bullets  after  entering  the  skin  described  a  circuitous  course 
through  the  subcutaneous  tissues  half-way  around  the  body.  In 
such  cases  the  wounds  of  entrance  and  exit  indicated  a  direct  course 
when  in  reality,  as  determined  by  autopsy  or  otherwise,  the  ball  had 
been  deflected. 

7.  Was  it  Accident,  Suicide  or  Homicide? — This  question  often 
comes  up  in  cases  of  death  from  gunshot  injury.  An  attempt  at 
suicide  shows  a  wound  directed  against  a  vital  part,  as  a  rule;  the  wound 
is  not  located  on  the  back  part  of  the  body.  A  suicide  often  selects 
the  inside  of  the  mouth  to  reach  the  vital  part  of  the  brain,  a  location 
that  could  not  be  selected  by  a  murderer,  except  on  helpless  individ- 
uals. In  368  suicides  by  firearms  in  France  297  were  from  wounds 
in  the  head;  of  these  234  were  fired  into  the  mouth,  only  seventy-one 
v.- ere  from  wounds  inflicted  on  the  chest  or  abdomen  (Reese).  The 
other  favorite  location  selected  is  the  temple  and  the  right  temple  is 
chosen  in  the  vast  majority  of  the  cases.  Suicidal  shots,  as  a  rule,  are 
delivered  at  close  range,  they  generally  show  powder  marks,  the  pene- 
tration and  distribution  of  which  should  be  carefully  studied  to 
ascertain  the  distance  from  the  muzzle  and  the  way  in  which  the 
weapon  was  held.  Here  we  refer  to  the  powder  brand  and  other 
evidence  from  the  explosive  which  has  figured  so  often  in  the  courts 
and  which  we  have  already  explained  at  length.  With  reference  to 
the  value  of  powder  brand  in  cases  of  suicide,  if  one  will  take  an 
unloaded  revolver  or  pistol  in  his  right  or  left  hand  and  go  through 
the  execution  which  a  suicide  must  follow  to  shoot  himself  he  will 
at  once  learn  the  limited  amount  of  motion  that  one  commands  in 


378  GUNSHOT   WOUNDS 

directing  the  hammer  to  the  right  or  left.  The  limit  of  movement 
when  aiming  at  a  target  corresponds  to  the  amount  of  pronation  and 
supination  of  the  wrist,  and  the  area  occupied  by  the  different  pow- 
der brands  on  blotting  paper  is  about  equal  to  a  semicircle.  A 
powder  brand  outside  this  semicirlce  should  favor  the  theory  of 
homicide. 

In  an  attempt  at  suicide  there  is  usually  evidence  of  design  which 
is  not  shown  in  cases  of  accident.  In  the  matter  of  design  suicides 
have  used  strange  weapons.  Many  unusual  devices  which  bear 
evidence  of  the  expenditure  of  time  and  thought  have  been  employed. 
Aside  from  the  ordinary  weapons  like  pistols,  rifles,  and  shotguns, 
they  have  been  known  to  extemporize  fowling-pieces  out  of  iron 
piping,  large  hollow  keys,  toy  cannons  and  bottles  charged  with 
explosives  and  sand,  or  gravel,  nails,  pieces  of  lead;  and  liquids  like 
water,  petroleum  and  rum  have  been  used  to  take  the  place  of 
ordinary  projectiles.  In  summing  up  the  evidence  in  a  given  case, 
one  should  not  lose  sight  of  the  fact  that  design  can  be  planned  by  a 
murderer  in  an  effort  to  conceal  crime.  The  shotgun  or  rifle  is  not  so 
often  employed  by  suicides,  but  when  used  there  is  usually  evidence 
of  design.  In  the  case  of  a  prominent  jurist  personally  known  to  the 
writer  a  shotgun  was  used.  A  string  about  2  feet  long  was  tied  by 
its  middle  to  one  of  the  triggers.  A  loop  to  admit  the  big  toe  was 
provided  in  each  end  of  the  string.  He  then  sat  on  the  edge  of  his 
bed  and  placing  the  muzzle  of  the  weapon  in  his  mouth,  the  gun  was 
discharged  by  pressing  the  toes,  which  had  been  previously  placed  in 
the  loops,  toward  the  floor. 

The  question  of  suicidal  or  self-inflicted  accidental  wounds  often 
figure  in  the  courts  with  a  bearing  on  insurance.  Wounds  from  both 
causes  will  have  the  characters  of  near  wounds.  When  the  body  or 
premises  have  not  been  disturbed,  the  relative  position  of  the  body 
and  weapon  will  give  evidence  of  the  presence  or  absence  of  design 
in  the  majority  of  cases. 

When  the  weapon  is  still  firmly  grasped  in  the  hand  it  is  proof 
positive  that  the  wound  was  self-inflicted,  but  it  affords  no  bearing  on 
whether  the  wound  was  suicidal  or  accidental.  The  facts  in  such  a 
case  must  come  from  other  evidence. 

When  a  wound  is  inflicted  by  accident  on  a  second  person,  it  is 
difficult  without  direct  evidence  to  say  whether  it  was  accidental  or 
homicidal.  In  such  cases  the  lesion  with  reference  to  wound  of  en- 
trance and  exit,  and  the  direction  of  the  channel  made  by  the  ball 


MEDICO-LEGAL    PHASES    OF   GUNSHOT   WOUNDS  379 

should  be  carefully  compared  with  the  statement  of  the  person  who  did 
the  shooting. 

With  old  firearms,  when  loading  was  done  by  hand,  wadding  from 
paper  and  other  material  found  in  a  wound  has  often  served  to  establish 
the  guilt  of  the  offender.  Thus,  hand-writing  on  paper  or  print  from 
paper  wadding,  has  been  found  in  some  cases  to  have  been  torn  from 
remaining  particles  in  the  possession  of  the  person  who  had  com- 
mitted the  crime.  Evidence  from  such  a  source  is  rare  now  because 
nearly  all  ammunition  is  loaded  by  machinery.  Still  the  projectile, 
wadding  if  any,  and  even  particles  of  the  explosive  should  be  carefully 
preserved  and  turned  over  to  competent  authority  for  future  study. 

Chemical  analysis  of  bullets  was  resorted  to  formerly  to  determine 
guilt  or  innocence.  Lead  bullets  are  now  hardened  with  antimony  and 
small  shot  contains  arsenic.  Old  fashioned  missiles  of  this  class  were 
composed  entirely  of  lead.  Lead  slugs  with  neither  antimony  nor 
arsenic  are  occasionally  used  in  shotguns.  Thus  in  a  case  cited  a 
number  of  deformed  shot  approaching  the  appearance  of  slugs  were 
removed  from  a  dead  body.  They  contained  arsenic,  but  slugs  found 
in  the  prisoner's  possession  were  arsenic-free. 

Since  the  weight  of  the  bullet  at  times  enters  into  a  case,  it  is  always 
well  to  take  the  weight  of  all  missiles  extracted  for  future  comparison. 

8.  Identity  of  the  Individual  by  the  Flash  of  the  Firearm. — With 
the  use  of  black  gun  powder  there  is  ignition  and  the  flash  from 
shotguns,  revolvers  and  pistols  containing  a  sufficient  charge  will 
illumine  the  vicinity  of  the  shooting  in  a  dark  room  enough  to  iden- 
tify the  features  of  an  individual  as  far  as  5  meters  when  the  observer 
is  placed  laterally  to  the  one  doing  the  shooting;  and  when  viewed 
while  facing  the  one  shooting,  the  latter  can  be  recognized  as  far  as 
10  meters.^  The  test  is  different  with  the  so-called  smokeless  powders. 
With  them  there  is  no  flash  at  the  time  of  discharge  because  there  is 
no  ignition  or  fire.  Experiments  with  black  powder  and  the  various 
brands  of  smokeless  powder  when  fired  into  blotting  paper  will  con- 
vince anyone  of  the  truth  of  this  statement.  We  have  shot  rifles, 
pistols  and  revolvers  loaded  with  smokeless  powder  in  a  basement 
when  the  space  was  absolutely  dark,  with  negative  results  in  all 
instances. 

9.  Self-inflicted  Non-fatal  Wounds. — Self-inflicted  wounds  are 
at  times  made  to  avoid  military  service,  to  elicit  money  or  charity, 
or  to  impute  murder.     Again  a  man  making  a  futile  attempt  at 

1  Dr.  Romary,  Arch.  D'Anth.  Grim.,  1908. 


380  GUNSHOT   WOUNDS 

suicide  will  often  endeavor  to  conceal  his  act,  and  ascribe  the  wound  to 
the  hand  of  an  assassin.  Examination  of  such  wounds  will  show  that 
with  the  exception  of  attempted  suicide  they  will  not  be  directed 
against  vital  parts.  The  skin  will  show  laceration,  ecchymosis,  smut, 
burn  or  tattoo  from  gun  powder.  Marks  of  the  powder  may  be  on 
the  hand  holding  the  weapon,  as  so  often  happens  in  self-inflicted 
wounds.  The  powder  brand  when  present  will  indicate  how  the 
weapon  was  held  with  reference  to  the  direction  of  the  hammer. 

10.  At  What  Time  Was  the  Firearm  Discharged? — This  resolves 
itself  into  a  very  important  question  in  many  cases  because  its  solution 
may  serve  to  identify  the  weapon.  If  black  powder  was  used  K2S 
will  be  found  in  the  barrel  shortly  after  discharge.  Later  oxidation 
produces  K2SO4.  Experiments  under  the  condition  of  moisture  and 
temperature  prevailing  at  the  time  of  discharge  should  give  the  time 
approximately.  The  author  is  not  acquainted  with  any  method 
which  will  fix  the  time  if  smokeless  powder  has  been  used. 

11.  Was  the  Projectile  Jacketed  or  Not? — The  effects  of  armored 
bullets  have  shown  such  distinguishing  characteristics  on  bone  when 
compared  to  the  lesion  inflicted  by  the  ordinary  lead  bullet,  as  shown 
by  dissection  and  the  appearance  outlined  on  an  X-ray  plate,  that 
they  deserve  special  mention  at  this  time.  The  use  of  jacketed  bullets 
is  becoming  more  and  more  popular  with  the  manufacture  of  pistols. 
The  question  of  the  kind  of  weapon,  as  well  as  the  kind  of  bullet, 
whether  jacketed  or  not,  can  be  established  by  strong  presumptive 
evidence  from  the  presence  or  absence  of  lead  particles  on  the  X-ray 
plate.  A  lead  bullet  fired  from  an  ordinary  revolver  at  moderate 
velocity  leaves  particles  of  lead  in  the  osseous  lesions  and  their  vicinity, 
in  nearly  every  instance;  and  the  reverse  is  true  if  the  lesion  has  been 
inflicted  by  an  automatic  pistol  carrying  a  jacketed  bullet.  The 
osseous  lesion  i  1  the  case  of  the  latter  is,  as  a  rule,  remarkably  free 
from  metallic  particles  unless  the  nose  of  the  bullet  has  been  marred 
by  filing,  etc.  Military  surgeons  in  the  wars  of  the  present  distin- 
guish at  a  glance  on  an  X-ray  plate  wounds  from  shrapnel  balls  which 
are  always  made  of  lead  from  those  inflicted  by  the  mantle  pro- 
jectiles of  the  reduced-caliber  rifle.  In  the  former,  in  the  osseous 
lesion  and  the  soft  tissues  beyond  the  point  of  impact  in  the  bone  one 
will  flnd  deposits  of  small  fragments  of  lead  distributed  in  a  stream-like 
manner.  The  bone  lesion  from  the  jacketed  bullet  is  usually  free  from 
metallic  particles  unless  there  has  been  separation  of  the  jacket  from 
the  lead  core.     Such  fragmentation  will  sometimes  take  place  when  the 


MEDICO-LEGAL   PHASES    OF   GUNSHOT   WOUNDS  381 

jacketed  bullet  makes  an  irregular  impact  against  the  bone  or  when 
its  jacket  has  been  impaired  by  ricochet  or  otherwise.  If  the  plate 
should  show  absence  of  lead  particle,  the  use  of  a  jacketed  bullet  is 
indicated  and  since  the  latter  are  only  used  in  pistols  of  the  automatic 
class  and  not  in  revolvers,  the  kind  of  weapon  also  becomes  apparent. 
A  study  of  figures  representing  X-ray  lesions  in  bone  in  other  chapters 
will  show  the  differences  referred  to. 

In  any  case  that  is  likely  to  go  before  the  courts,  the  examiners 
should  take  careful  notes  at  the  time  of  the  first  examination,  and 
preserve  these  for  future  reference.  The  exact  location  of  the  en- 
trance and  exit  wounds,  if  the  latter  is  present,  should  be  noted.  The 
character  of  the  wounds,  their  size  and  shape,  their  condition  as  to 
laceration,  the  character  and  amount  of  hemorrhage  and  evidence  as 
to  powder  brand  and  tattooing  will  be  important  points  to  note. 
When  a  post-mortem  is  held,  minute  notes  should  be  taken  of  the  find- 
ings, and  filed.  The  condition  of  the  weapon,  its  location  when 
found,  the  presence  or  absence  of  smut  in  the  barrel  should  also  be 
noted. 

In  the  foregoing  medico-legal  phases  of  gunshot  wounds  we  have 
endeavored  to  consider  the  majority  of  the  questions  that  are  likely 
to  come  up  in  courts  of  law.  There  are  doubtless  many  more  that 
writers  on  the  subject  cannot  foretell.  Thus  the  dangers  from 
certain  body  wounds  and  the  complications  likely  to  set  in  cannot 
be  dealt  with  at  length  in  this  chapter.  They  can  only  be  grasped  by 
a  careful  study  of  the  chapters  devoted  to  these  subjects.  For  further 
particulars  on  the  various  kinds  of  explosives,  firearms,  projectiles  and 
the  characteristic  features  of  gunshot  wounds  by  different  weapons  the 
reader  is  referred  to  Chapters  I  and  II. 


CHAPTER  XIV 

Field  X-ray  Apparatus 

The  importance  of  radiography  in  dealing  with  mihtary  surgical 
cases  in  war  has  long  been  recognized,  and  many  different  types  of 
apparatus  have  been  devised  for  doing  radiography  under  the  condi- 
tions of  active  service.  Up  to  the  present  time,  however,  no  apparatus 
has  been  free  from  some  one  or  more  serious  defect.  The  essential 
features  of  a  field  X-ray  apparatus  are  sufficient  power  for  good  radi- 
ography and  at  the  same  time  portability,  compactness,  and  durability. 

The  use  of  galvanic  cells  in  connection  with  a  coil  was  one  of  the 
first  types  suggested  for  field  apparatus.  It  is  a  laboratory  possibility 
to  illuminate  a  Crooke's  tube  by  a  series  of  galvanic  cells,  but,  owing 
to  the  small  current  produced,  the  quantity  and  quality  of  the  radia- 
tions are  unsatisfactory. 

Static  machines  were  designed  but  were  abandoned  on  account  of 
numerous  difficulties  attending  their  operation.  They  were  too 
cumbersome,  too  fragile,  and  extremely  unreliable.  Hand  power 
applied  to  a  static  machine  is  a  poor  method  of  operating  the  machine, 
so  that  an  engine  must  be  provided  for  uniform  high  speed.  If  an 
engine  were  available,  however,  it  would  be  better  to  employ  it  with  a 
coil-dynamo  apparatus  which  is  of  greater  radiographic  efficiency. 

During  the  Boer  War,  accumulators  were  frequently  used  with 
coils  by  English  medical  officers,  and  appear  to  have  given  satisfaction. 
There  are  two  objections  to  the  use  of  accumulators  that  prevent  their 
adoption  for  field  service.  Their  weight  is  excessive,  but  this  is  not  so 
objectionable  as  the  fact  that  they  require  an  electrical  supply  to 
recharge  them.  If  no  means  of  recharging  the  apparatus  be  available, 
it  is  worthless  in  that  locality.  The  recharging  of  accumulators 
requires  a  direct  current,  but  an  alternating  current  can  be  used  after 
passing  it  through  a  rectifier.  The  absence  of  this  rectifier,  however, 
would  preclude  recharging.  Accumulators  may  at  times  be  employed 
for  field  X-ray  work,  but  the  ideal  apparatus  for  this  purpose  must  be 
self-contained  and  operable  at  any  time  and  under  all  circumstances. 

Among  the  early  forms  of  apparatus  were  coil-dynamo  machines 

382 


FIELD   X-RAY   APPARATUS  383 

operated  by  man  or  horse-power,  a  revolving  shaft  transmitting  the 
power  to  the  dynamo.  A  tandem  bicycle  was  also  used,  being  con- 
structed so  that  it  could  be  connected  to  a  dynamo  by  a  chain  drive. 
These  methods  were  never  found  satisfactory,  as  sufficient  power 
could  not  be  generated.  Later  a  gasohne  engine  was  employed  to 
furnish  the  power  and  was  found  practical. 

The  coil-dynamo  machine  operated  by  a  gasoline  engine  is  one  of 
the  best  types  of  field  X-ray  apparatus  and  the  medical  departments 
of  most  armies  have  adopted  it.  Difficulties  that  have  attended  the 
operation  of  this  apparatus,  in  most  instances,  have  been  with  the 
engine.  No  gasoline  engine  has  been  found  that  has  given  perfect 
satisfaction  when  operated  in  connection  with  a  coil  apparatus.  _  The 
difficulties  have  chiefly  been  with  vibration  and  in  an  annoying  varia- 
tion in  the  speed  of  the  engine  when  the  current  is  switched  on  and 
off  the  coil.  Small,  one-cylinder  marine  engines  of  \\  to  3  H.P. 
acquire  a  marked  vibration  when  running  at  full  speed  and  must  be 
anchored  securely  to  a  base.  This  vibration  is  reduced  in  a  two- 
cylinder  engine  which  weighs  only  slightly  more,  runs  much  better, 
and  is  altogether  more  satisfactory.  The  variation  in  the  speed  of  the 
engine  is  due  to  the  peculiar  conditions  attending  the  operation  of  a 
coil.  Ordinarily  a  gasoline  engine  runs  under  a  uniform  load  through- 
out its  operation,  but  with  a  coil  it  is  subjected  to  a  sudden  change 
from  no  load  to  full  load  and  vice  versa.  When  the  current  from  the 
generator  is  switched  into  the  coil,  the  engine  drops  slowly  in  speed 
and  the  voltmeter  will  show  a  corresponding  fall.  Opening  up  the 
throttle  to  a  greater  degree  will  slightly  counteract  this  retardation. 
Upon  throwing  off  the  coil  switch  which  removes  the  load  from  the 
engine,  there  is  a  sudden  acceleration  in  its  speed,  and  the  throttle 
should  be  adjusted  accordingly.  This  action  is  much  less  marked 
in  a  two-cylinder  engine  of  4  to  6  H.P.  operating  a  2-K.W.  generator. 

The  ignition  devices  on  gasoline  engines  for  field  X-ray  apparatus 
are  important  and  require  some  consideration  in  their  selection.  A 
good  reliable  high-tension  magneto  should  be  used.  The  use  of  dry- 
cell  batteries  to  initiate  the  current  necessary  for  the  spark  plug  is 
objectionable.  They  become  exhausted  in  time  and  must  be  replaced 
by  new  ones.  This  may  occur  in  the  field  at  times  when  no  cells  are 
procurable. 

Recently  a  5-H.P.  motor-cycle  engine  was  used  to  operate  an 
interrupterless  apparatus  constructed  for  field  service.  It  was  run 
at  a  speed  of  about  1200  R.P.M.     This  is  much  faster  than  a  marine 


384  GUNSHOT    WOUNDS 

engine  and  makes  it  possible  to  connect  engine  and  generator  by  the 
same  shaft.  The  engine  worked  satisfactorily  but  there  was  some 
difficulty  in  cranking.  A  spring  cranking  device  has  been  used  but 
with  only  small  success. 

The  desired  current  for  a  field  X-ray  machine  is  about  20  amperes 
at  110  volts  which  is  furnished  by  a  2-K.W.  generator.  A  generator 
of  2-K.W.  capacity  requiring  a  speed  of  600  to  800  R.P.M.  is  too  heavy 
for  field  use  and  selection  must  be  made  from  the  smaller  types  that 
deliver  the  same  current  at  1200  to  1800  R.P.M.  This  speed  is  in 
excess  of  that  of  the  ordinary  marine  engine  and  consequently  it  is 
necessary  to  connect  engine  and  generator  by  a  chain  drive  for  multi- 
plication. The  high  speed  of  the  motor-cycle  engine  makes  it  possible 
to  mount  the  generator  and  engine  on  the  same  shaft,  and  for  this 
reason,  together  with  its  comparative  light  weight,  it  is  a  desirable 
engine  for  field  apparatus.  However,  the  excessive  vibration  of  an 
engine  which  runs  at  this  speed  is  a  serious  disadvantage.  It  must  be 
overcome  by  means  of  one  of  the  various  forms  of  shock  absorbers,  else 
an  outfit  will  soon  shake  itself  to  pieces. 

The  best  coil  for  general  radiography  is  one  of  10-12-inch  sparking 
distance.  This  size  is  the  one  sold  by  most  X-ray  apparatus  manu- 
facturers. It  is  not  excessive  in  weight  and  is  best  suited  to  our 
purpose. 

Of  the  several  types  of  interrupters  now  on  the  market,  none  have 
given  as  much  satisfaction  as  the  electrolytic.  A  mechanical  in- 
terrupter would  be  an  ideal  apparatus  provided  a  high  speed  of 
interruptions  could  be  maintained  without  injury  to  its  parts  when 
working  with  strong  currents.  A  simple  mechanical  interrupter  of 
the  App  or  vril  type  is  not  satisfactory  when  working  with  a  20- 
ampere  current  at  110  volts  pressure,  since  the  contact  points  become 
burned  out  and  the  apparatus  ceases  to  work.  Various  mercury 
turbine  interrupters  have  been  tried  but  they  are  inferior  to  the 
electrolytic.  The  great  objecticn  to  the  electrolytic  interrupter  is 
the  necessity  of  equipping  the  apparatus  with  a  large  amount  of 
sulphuric  acid,  for  there  is  always  the  risk  that  the  glass  bottles 
containing  this  acid  will  become  broken  in  transportation  and  cause 
much  damage.  To  offset  this  disadvantage  it  has  been  suggested  that 
chromic  acid  be  used  instead  of  sulphuric.  Chromic  acid  is  crystal- 
line, can  be  readily  handled,  and  in  1  to  10  aqueous  solution  works 
well. 

During  the  past  year  the  Medical  Department,  U.  S.  Army,  has 


FIELD   X-RAY    APPARATUS 


385 


carried  on  a  number  of  experiments  with  field  X-ray  outfits.  Instead 
of  using  the  induction  coil,  all  the  outfits  are  of  the  interrupterless 
type.  They  consist  of  a  gasoline  engine,  5  to  7  H. P.,  directly  connected 
to  drive  a  2  K.W.  A.C.  generator.  From  the  generator  the  current 
passes  to  a  transformer  where  the  voltage  is  stepped  up  to  about 
100,000  volts.  On  the  same  shaft  as  the  generator  and  engine  is  fixed 
a  mechanical  rectifier  or  commutator  so  adjusted  that  its  poles  convert 
the  two  pulsations  of  the  A.C.  coming  from  the  transformer  into  a 
pulsating  direct  current  which  passes  to  the  X-ray  tube.     The  opera- 


FiG.  157. — Type  of  field  X-ray  apparatus  with  motor-cycle  engine.  1,  Engine;  2,  motor;  3, 
transformer;  4,  box  containing  revolving  rectifying  switches;  5,  cable  containing  wires  for  circuit 
from  motor  through  primary  of  transformer  and  return;  6,  secondary  terminals  of  transformer; 
7,  terminals  through  which  current  is  carried  from  rectifying  switches  to  the  X-ray  tube. 

tion  of  the  engine  and  the  control  of  the  current  is  accomplished  by  a 
simple  adjustment.  Two  types  of  engines  have  been  used,  a  small 
two-cyhnder,  6-H.P.  marine  engine,  and  a  7-H.P.  motor-cycle  engine. 
The  former  operates  at  a  lower  speed  than  the  latter,  and  vibration  is 
therefore  not  so  marked.  With  each  outfit  excellent  radiographic 
work  has  been  done.  Each  outfit  is  complete  in  itself,  being  equipped 
with  all  the  photographic  supplies  necessary.  The  outfits  are  so  con- 
structed that  they  can  be  quickly  and  securely  packed  for  transporta- 
tion, and  the  containers  are  so  fashioned  and  so  proportioned  that 
they  can  be  easily  handled  and  packed  in  the  ordinary  army  four- 
horse  wagon.     The  specifications  from  the  Surgeon-General's  office 


386 


GUNSHOT   WOUNDS 


limits  the  weight  of  the  apparatus  to  2000  pounds,  and  the  maximum 
weight  of  the  various  u/_its  in  which  it  is  packed  for  transportation  to 
400  pounds.  This  division  of  weight  into  several  parts  is  an  important 
factor  in  handling  the  apparatus,  as  each  boxed  unit  can  be  readily- 
carried  by  a  squad  of  four  men. 

Several  outfits  have  been  constructed  and  are  now  installed  at 
post  hospitals  for  further  observation  as  to  their  durability  and  radio- 


FiG.  158. — Type  of  field  X-ray  apparatus  with  marine  engine.  1,  Engine;  2,  motor;  3,  trans- 
former; 4,  rectifying  switches;  5,  cable  containing  wires  for  circuit  from  motor  to  primary  of  trans- 
former and  return;  6,  secondary  terminals  of  transformer;  7,  terminals  through  which  current  is  car- 
ried from  rectifying  switches  to  X-ray  tube;  8,  X-ray  tube;  9,  packing  bo.x  utilized  as  table;  10, 
plate  holder. 


graphic  efficiency.  Three  of  these  outfits  are  shown  in  Figs.  157,  158, 
159.  They  are  in  constant  use  and  all  defects  in  construction  are  being 
carefully  recorded.  It  is  hoped  that  in  a  short  time  sufficient  informa- 
tion will  have  been  obtained  to  enable  the  department  to  determine  the 
most  satisfactory  engine  for  use  with  these  outfits.  Experiments 
thus  far  seem  to  indicate  that  the  motor-cycle  engine,  while  light  and 
very  powerful,  is  too  complicated  and  delicate  for  use  with  these 
machines.     It  is  believed  that  these  experiments  will  show  that  a 


FIELD   X-RAY    APPARATUS 


387 


low-speed  marine  engine  geared  or  belted  to  the  generator  will  prove 
to  be  the  most  suitable  motive  power,  these  engines  being  simple  in 
construction,  easily  operated  under  almost  any  conditions,  having  very 
few  parts,  and  being  much  more  durable  than  the  complicated  light- 
weight engine.  As  the  X-raj'  outfits  cannot,  in  the  field,  serve  any 
purpose  at  the  front — in  fact,  are  not  practical  or  needed  further 
forward  than  the  more  or  less  stationary  evacuation  hospitals,  the 
increased  weight  occasioned  by  using  the  slow-speed  powerful  engine 
is  not  a  serious  disadvantage. 


Fig.  159, — Latest  type  of  field  X-ray  apparatus  -n-ith  marine  engine.  1,  Engine;  2,  motor;  3, 
transformer;  4,  revolving  rectifying  disc;  5,  cables  containing  wires  for  circuit  from  motor  through 
primary  of  transformer  and  return;  6,  box  containing  X-ray  tube  mounted  so  as  to  slide  on  hori- 
zontal rods;  7,  army  stretcher;  8,  canvas  strip  weighted  at  ends  to  hold  plate  in  position. 

Tubes. — Each  apparatus  should  be  equipped  with  at  least  four 
6-inch  or  7-inch  tungsten  target  tubes.  To  prevent  breakage  in 
transportation  these  tubes  must  be  securety  packed.  This  is  quite 
satisfactorily  accomplished  by  having  a  special  chest  made  up  for  the 
tubes  with  holders  in  which  each  tube  can  be  placed,  the  chest  and 
holders  being  thoroughh^  lined  with  very  thick  and  soft  padding 
materials.  Breakage  is  certain  to  be  a  great  factor  in  any  scheme  of 
packing  tubes.  If  space  is  not  a  factor,  tubes  should  be  packed  in 
excelsior  and  each  tube  inclosed  in  a  separate  box. 

Table. — For  use  wdth  the  portable  apparatus  described  above, 


388 


GUNSHOT   WOUNDS 


The  Roentgen  Mfg.  Co.  of  Philadelphia  has  devised  an  excellent 
portable  table  which  can  be  conveniently  folded  up  for  transportation. 
It  is  constructed  so  that  an  army  stretcher  forms  the  couch  under 
which  plays  a  tube  supported  in  a  suitable  tube  holder.  The  tube 
holder  can  be  displaced  along  the  length  of  the  couch,  while  the  litter 
can  be  moved  laterally,  the  combination  of  movements  making  it 
possible  to  radiograph  any  part  of  a  patient  without  disturbing  him. 
The  plate  is  held  by  a  canvas  strip  weighted  at  both  ends,  so  that  when 
it  is  placed  over  the  plate  it  holds  it  securely  in  position.     With  this 


L.  GLASS  SHIELD 


TUBE  HOLDER 


TOP  OF  ONE  OF  THE 
PACKING  BOXES  PLACED 
ON  ITS  SIDE  AND  USED 
AS  AN  OPERATING  TABLE. 


CROSS  CONNECTION  WITH  A 
CLAMPING  DEVICE  TO  FIX  IT 
IN  ANY  POSITION  ON  VERTICAL 
ROD,  AND  A  SECOND  CLAMP  TO 
FIX  THE  POSITION  OF  THE 
HORIZONTAL  ROD. 


1'4    PIPE  WHICH  SLIDES  THROUGH 
HORIZONTAL  OPENING  OF  THE 
CROSS  CONNECTION  TO  BE  LONG 
ENOUGH  TO  SUPPORT  THE  TUBE 
OVER  PISTAL  EDGE  OF  TABLE. 

-2"PIPE 


ETAL  COLLAR  FASTENED  IN 
UPPER  SIDE  OF  BOX  WITH  AN 
OPENING  THROUGH  WHICH  THE 
VERTICAL  ROD  CAN  BE  PASSED. 


-VERTICAL  ROD  OF  TUBE 
SUPPORTING  DEVICE,  THIS 
CAN  BE  SLIPPED  INTO 
POSITION  WHEN  BOX  IS 
PLACED  ON  rrs  SIDE. 


METAL  PIECE  FASTENED  IN 
LOWER  SIDE  OF  BOX  WITH  AN 
OPENING  TO  RECEIVE  AND 
SECURELY  FASTEN  FOOT 
OF  VERTICAL  ROD  SO  IT  CAN 
NOT  TURN  OR  SLIP  OUT. 


Fig.   160. 


form  of  table  excellent  radiographic  work  can  be  done.  However,  it 
is  believed  more  satisfactory  radiographs  can  be  made  if  the  tube  is 
supported  above  the  patient.  In  addition  it  does  not  seem  necessary 
to  increase  the  weight  of  an  outfit  with  a  special  operating  table,  when 
the  apparatus  must  be  packed  in  a  number  of  large  boxes  one  or  more 
of  which  can  be  utilized  as  a  table.  Means  can  easily  be  provided  for 
supporting  an  adjustable  tube  holder  above  one  of  the  boxes.  Fig.  160 
shows  a  rough  sketch  of  a  table  of  this  kind,  one  of  which  has  been 
made  up  by  the  Waite  &  Bartlett  Co.  of  New  York  City  in  connec- 


FIELD  X-RAY   APPARATUS  389 

tion  \\dth  a  field  X-ray  apparatus  built  by  this  company,  and  it  has 
proven  entirely  satisfactory. 

Dark  Room. — The  Surgeon-General's  office  has  had  several 
portable  cabinets  constructed,  all  of  which  have  for  a  time  proven 
satisfactory.  But  these  cabinets  are  not  durable  and  under  the  rough 
usage  incident  to  field  service  the  materials  of  which  they  are  con- 
structed cannot  be  depended  upon  to  provide  a  light-proof  compart- 
ment. Pending  further  developments  in  the  line  of  portable  dark  room 
it  seems  that  in  the  field  some  of  the  numerous  forms  of  developing 
tanks  must  be  used  for  developing  X-ray  plates.  These  tanks  give 
good  results  and  while  their  product  may  not  be  equal  to  that  which 
can  be  obtained  in  a  well-equipped  dark  room,  yet  the  plates  produced 
furnish  all  the  information  ordinarily  required  under  field  conditions. 

The  accessories  required  for  a  complete  field  apparatus  are  a  supply 
of  X-ray  plates,  fluoroscope,  lenticular  stereoscope,  chemicals  for 
development  and  printing,  trays,  printing  paper  and  frames,  orange 
and  black  envelopes  for  the  protection  of  plates,  graduates,  tool  kit 
and  important  spare  parts  for  the  engine,  and  a  tank  for  gasoline. 

A  field  X-ray  apparatus  in  order  to  be  portable  must  either  be 
mounted  on  an  automobile  or  wagon  bed  or  divided  into  several  parts 
which  can  be  boxed.  The  French  Army  has  constructed  an  X-ray 
automobile,  which  is  said  to  be  very  satisfactory.  Its  engine  provides 
power  for  the  operation  of  the  apparatus.  The  German  Army  uses  a 
wagon  and  their  apparatus  is  one  of  the  best  for  field  service.  The 
apparatus  used  b}^  the  United  States  Army  is  contained  in  several 
boxes  which  can  easily  be  loaded  into  an  escort  wagon.  The  last 
method  appears  to  be  practical  and  reliable.  Disabling  accidents  are 
liable  to  happen  either  to  an  automobile  or  wagon,  especially  the 
former,  so  that  the  construction  of  an  X-ray  apparatus  permanently 
upon  either  does  not  appear  to  be  as  good  as  separate  boxing.  The  last 
method  is  certainly  best  adapted  for  boat  and  railroad  transportation. 

In  regard  to  the  proper  points  at  which  field  X-ray  apparatus  should 
be  operated  when  an  army  is  in  active  service,  it  is  the  general  opinion 
that  they  are  not  required  further  forward  than  the  stationary  hospitals 
along  the  lines  of  communication.  They  should  not  be  a  part  of  the 
equipment  of  a  field  hospital.  According  to  the  present  organization 
of  our  medical  department,  field  hospitals  are  daily  evacuated 
to  the  stationary  hospitals,  and  all  cases  that  require  skiagraphy 
can  safely  stand  the  delay  of  a  day  or  two  incident  to  their  arrival 
at  the  hospitals  in  the  rear.     The  presence  of  an  X-ray  apparatus  at 


390  GUNSHOT   WOUNDS 

a  field  hospital  would  tend  to  foster  unnecessary  surgical  interference 
and  add  greatly  to  the  work  at  that  point.  The  large  military  hospitals 
at  the  base  vnW  be  equipped  with  permanent  X-ray  apparatus,  but 
it  is  probable  that,  at  the  beginning  of  a  campaign,  it  will  there  be 
necessary  to  use  portable  outfits  while  awaiting  the  installation  ol 
other  apparatus.  In  this  connection  it  is  to  be  stated  that  there 
is  some  difl&culty  attending  the  initial  installation  of  permanent  coils 
and  other  X-ray  apparatus,  owing  to  variations  in  local  electrical 
currents.  If  the  character  of  the  electrical  supply  for  a  particular 
place  be  known,  the  supply  department  can  provide  an  apparatus 
constructed  for  that  current.  In  supplying  an  X-ray  apparatus  for 
a  certain  place  it  is  necessarj^  to  know  the  character  of  the  current, 
whether  direct  or  alternating;  the  voltage;  and,  if  the  current  be  alter- 
nating, its  cycle  and  phase. 

The  construction  of  portable  field  X-raj^  apparatus  has  not  yet 
reached  perfection  but  every  endeavor  is  being  made  by  the  Surgeon- 
General's  office  to  secure  an  apparatus  that  will  warrant  its  use  at  army 
posts  during  times  of  peace,  so  that  medical  officers  will  become 
familiar  with  the  operation  of  the  apparatus  and  there  will  be  a  large 
supply  of  field  outfits  available  at  once  for  service  during  active 
warfare. 


INDEX 


Abdomen,  contusions  of,  226 
wounds  of,  226 

of  adrenal  gland,  269 

of  classification,  226 

considered  from  the  standpoint 
of  the  military  and  civil  sur- 
geon, 243 

contra-indications  to  operation 
in,  255 

changes  in  the  lesions  of,  in 
recent  times,  and  the  causes 
therefor,  253 

facts  to  be  remembered  in  the 
presence  of,  238 

from  the  Spanish-American  War, 
244 

of  kidne}^  267 

of  large  intestine,  261 

of  hver  and  gall-bladder,  262 

of   non-penetrating,    229 

pancreas,  265 

penetrating,  230 

perforating,  236 

positiA^e  signs  of  intestinal  per- 
foration in,  240 

prognosis   and    fatalitj^  of,    241 

sigmoid  flexure  and  rectum,  261 

small  intestine,  257 

spleen,  266 

steps  to  be  observed  during 
operation,  257 

stomach,  260 

treatment  in  military  and  civil 
practice,  243 

m-inary  bladder,  269 
Abscess  of  brain,  182 
Air  resistance  on  projectiles,  24 
Ammunition,  of  1906  for  United  States 
rifle,  8,  31 
blank,  15 
supply  of  field  guns,  16 


Aneurysm,  arterio-venous,  280 

diffuse  and  cu'cumscribed,  277 

traumatic,  276 

varicose,  282 
Aneurysmal  varix,  280 
Ankle,  wounds  of,  327 
Antelo,    Colonel,    Argentine  Army,  on 
the  use  of  iodine  in  military 
surgery,  141 
Anthrax  bullets,  133 
Automatic  pistol,  Colts,  10 

pistols,  table  number,  3,  70,  71 

rifle,  32 


B 


BaUistics,  23 

of  pistols  and  revolvers.   Table  3, 

70,  71 
Bergmann,     Von,     on    antiseptics    in 

mihtary  surgery,  148 
Bladder,  urinary,  wounds  of,  262 
Blood-vessels,  contusion  of  arteries,  275 
injury  to  by  reduced  caliber  bullets, 

54 
partial   and   complete   division   of 

arteries,  276 
traumatic     aneiirism    of    arteries, 
276 
Brain,   injui-y  to,   in  fractures   of   the 

skuU,  158 
Breech-loading  rifles,  6 
Bombs,  19 
Bone,    injury    to    by    reduced    caUber 

bullets,  54 
Bones,  contusions  of,  332 
Borden,    Col.,   W.  C,  U.  S.  Army,  on 

the  frequency  of  spinal  injuries 

in  modern  wars,  201 
Bornhaupt,  abdominal  wounds  by  the 

Japanese  bullet  in  the  Man- 

chmian  campaign,  246 


26 


391 


392 


INDEX 


Bullet,  "S,"  "Spitz,"  or  pointed  bullet, 
wounds  by,  56 

Bullets  from  pistols  and  revolvers, 
with  truncated  cone,  spheri- 
cal segment,  soft-nose,  blunt 
point,  hole  in  point,  man-stop- 
per, and  theu-  effects  on  dead 
and  Uving  tissues  experimen- 
tally considered,  68 


C 


Cadavers,   value  of  experimental   evi- 
dence by  firing  into,  as  com- 
pared to  the  evidence  in  the 
hving,  41 
Canister,  16 
Cannon,  hand,  3 
Carbine,  9 
Case-shot,  16 

Chest,  gunshot  fractures  in  wounds  of, 
214 
humane    character    of  wounds  by 

reduced  caUber  bullet,  216 
lodgment  of  bullets  in,  222 
non-penetrating  wounds  of,  214 
penetrating  wounds  of,  215 
treatment  of  wounds  of,  230 
wounds  by  the  new  armament  in 
the  Santiago  compaign,  214 
by  the  old  armament,  214 
certain  symptoms  and  complica- 
tions, 218 
Clothing,   character  of  perforation  of, 
a  medico-legal   question,    373 
Colt's  automatic  pistol,  table  number  3, 
70,  71 
revolver,  table  number  3,  70,  71 
Contusion  of  bones,  332 
of  leg,  356 

treatment  of,  356 
Cord,  spinal,  concussion  of,  by  large  and 
small  caUber  bullets,  302 
contusion  of,  203 
prognosis  in  g.  s.  injury  of,  210 
symptoms  foUoTvang  g.  s.  injury 

of,  207 
treatment  in  g.  s.  injmy  of,  211 


Cord,  spinal,  varying  lesions  of,  by  re- 
duced caliber  bullets,  202 

Cranium,  g.  s.  wounds  of,  in  Civil  War, 
156 
fractm-e  in  (see  Skull),  158 

D 

Delorme,  E.,  on  the  character  of  bony 

lesions  of  the  spine  by  the  new 

armament,  202 
Delvigne,  Capt.  of  French  Army,  5 
Desarlo,  Capt.  Eugenio,  Itahan  Army, 

on    the    use  of  iodine  in  the 

ItaUo-Tm-kish  War,  142 
on    laparotomy    in    the    Italio- 

Tm-kish  War,  248 
Detectors  and  Extractors,  150 
Deubler,  on  tetanus  in  Austrian  Army, 

134 
Diagnosis  of    a  wound   by  firearms,  a 

medico-legal  question,  367 
Diaphyses  of  long  bones,  g.  s.  injuries 

of,  332 
Doebbehn's    case    of    injury    by    the 

pointed  or  "Spitz"  bullet,  57 
Doepner,  wounds  by  Flobert  rifle,  110 
Douglas,     Dr.    Richard,    mortality    in 

abdominal  wounds   subjected 

to  operation,  244 
Dorst,   on  predisposition  to  tetanus  in 

wounds  with  hematoma,   136 
Dujardin    Beaumetz,    on  the  value  of 

experimentation  by  firing  into 

cadavers,  42 


E 


Elbow-joint,  wounds  of,  302 
Explosives,  11 

Explosive  effects  of  bullets  from  hand- 
weapons,  36 
explained,  90 


Fauntleroy,  Major  P.  C,  M.  C,  U.  S.  A., 
abdominal  wounds  in  the 
Turko-Balkan  War,  254 


INDEX 


393 


Fauntleroy,  on  the  effects  of  the  pointed 
bullet  in  Turko-Balkan    War, 
1912-13,  60 
casualties  in  Turko-Balkan  War, 

1912-13,  60 
the  ratio  of  shrapnel  wounds  in 
the  Turko-Balkan  War,  106 
Femur,  gunshot  injuries  of  shaft  of,  349 
shot  contusion  of,  349 
treatment  of  g.  s.  fractures  of,  by 
conservation,  350 
by  amputation,  354 
Fenner,    Dr.    E.    D.,    laparotomy    in 
Charity    Hospital,    New    Or- 
leans, La.,  251 
mortahty  of  abdominal  wounds 
subjected  to  operation,  244 
Fu'earms,  2 

distance    of    weapon    when     dis- 
charged, a  medico-legal  ques- 
tion, 369 
when    discharged,    a    medico-legal 
question,  380 
First-aid  package,  components  of,  141 
Fischer,  Dr.  G.,  on  the  use  of  iodine  in 
the  Manchurian  campaign,  142 
the  location  of  heart  wounds,  224 
Fish,  Dr.  B.  F.  N.,  on  "powder-brand," 

a  medico-legal  question,  369 
Flash,   from  firearms,   identity   of  the 
individual  hj,  a  medico-legal 
question,  379 
Flint-lock,  4 

Follenfant,  laparotomy  in  the  Manchu- 
rian campaign,  246 
malignant    pustule    in    E,  u  s  s  o  - 

Japanese  War,  133 
on    the    infrequency    of    primary 
hemorrhage     in     the     Russo- 
Japanese  War,  119 
shrapnel   wounds,    in    the    Russo- 
Japanese  War,  105 
wounds  of  air  passages  in  Manchu- 
rian campaign,  198 
Forearm,  fractures  of,  341. 

treatment  of  fractures  of,  by  con- 
servation, 344 
by  amputation,  346 


Foreign  bodies,  carried  in  wounds,  53 
Foot,  gunshot  wounds  of,  364 
Fracture  of  cranium  (see  Skull),  157 
Fractures,  simple  and  compound,  335 
Fulminate-powders,  12 


G 


Gall-bladder,  wounds  of,  262 
Genital  organs,  external,  wounds  of,  271 
Girard,  General,  M.  C,  U.  S.  A.,  on  a 
g.  s.  wound  of  head  by  Krag- 
Jorgensen  bullet,  174 
Grenades,  hand  and  rifle,  19 
Grossich,  Dr.,  on  the  use  of  iodine,  in 

wound  treatment,  142 
Gun,  flint-lock,  4 
hand,  3 
match-lock,  3 
percussion  cap,  4 
snaphaunce,  3 
wheel-lock,  3 
Guns,  large,  2 

service  machine,  2 
Gunshot  fractures   of   cranium,    treat- 
ment of,  182 
wounds  of  the  spine,  200 
examination  of,  149 
of  the  head,  face  and  neck,  155 
ratio  of,  155 
Gun-powder,  11 


H 


Hall,  Dr.  J.  N.,  on  evidence  of  burn  on 
clothing,  a  medico-legal  ques- 
tion, 370 
Hand,  gunshot  wounds  of,  346 
Hand  weapons,  3 

Havard,  Valery,  Col.  M.  C,  U.  S.  A., 
abdominal     wounds     in     the 
Manchurian  campaign,  246 
infection  of  g.  s.  wounds  in  the 
Russo-Japanese  War,  130 
Head,  injuries  of  (see  Skull),  155 

wounds    of,    by    reduced    caliber 
bullets,  56 
brain  abscess  in,  182 


394 


INDEX 


Head  wounds,  concussion,  compression 
and  hemorrhage  in,  180 
herm'a,  cerebri  in,  181 
remote  effects  of,  180 
Heart  and  pericardium,   g.  s.  wounds 

in,  223 
Hemorrhage,  arrest  of,  140,  152 

as  a  symptom  of  g.  s.  wound,  1 18 
external  primary,  118 
internal  primary,  118 
recurrent,  118 
Hernia  cerebri,  181 
Hip-joint,  wounds  of,  309 
Hoff,  John  Van  R.,  Col.,  M.  C,  U.  S. 
Army,  on  abdominal  wounds 
in  the  Manchurian  campaign, 
247 
case  of  Corpl.  Linn,  317 
Howitzers,  2 
Humerus,  g.  s.  fractures  of,  336 

treatment  by  amputation,  339 
conservation,  337 
Hydraulic  theory  of  "explosive  effects," 
91 


Immobilization,   its   value  in   all   g.  s. 

wounds,  144 
Infection  in  g.  s.  wounds,  122 

by  modern  armament,   126 
constitutional  and   local    resist- 
ance to,  123 
'  influenced  by  sectional    area  of 
projectile,  122 
source  of,  123 

virulence  of  microorganisms  in, 
124 
prevention  of,  141 
in  g.  s.  wounds,  rules  to  prevent 
the  same,  147 
Intestine,  large,  wounds  of,  261 

small,  wounds  of,  257 
Iodine,  tincture  of,  in  wound  treatment, 
142 

J 

Joints,  gunshot  wounds  of,  289 


Joints,  amputation  in,  296 

ankle,  327 

classification  of,  291 

conservative  treatment  in,  297 

by  Hickson,  Colonel,  S.,  R.  A.  M.- 
C,  329 

humane  effects  of  new  arma- 
ment in,  289 

knee,  319 

of  elbow,  302 

of  hip-joint,  309 

of  shoulder-joint,  298 

of  wrist,  307 

percentage  of  mortality  and 
cause  of  death,  in  five  wars,  290 

primary  excision  in,  297 

suppuration  in,  298 

symptoms  of,  295 

treatment  of,  296 

vibration  synovitis,  from  new 
armament,  291 


K 


Kidney,  wounds  of,  267 

Knee-joint,  results  in  treatment  of,  in 
preantiseptic  times  and  under 
modern    methods    compared, 
128 
wounds  of,  319 

Krag-Jorgensen  rifle,  6 


Laminectomy  in  gunshot  injuries  of  the 
spine,  212 

Laparotomy,     contra-indications     and 
indications  for,  255,  256 
for  g.  s.  wounds,  256 

Lead,  bullets,  pellets,  etc.,  chemical 
analysis  of,  a  medico-legal 
question,  379 

Leg,  g.  s.  fractures  of,  357 

Lissak,  Lt.  Col.  Ormond,  M.,  on  ammu- 
nition supply  of  field-guns,  18 

Liver,  wounds  of,  262 

Longmore,  Sir  Thomas,  on  the  use  of 
steel  bullets,  129 


INDEX 


395 


Lowitch,  on  the  influence  of  hematoma 
in  the  development  of  tetanus, 
136 

Luger's  automatic  pistol,  table  number 
3,  70-71 

Ljmch,  Chas.,  Major,  M.  C,  JJ.  S.  A., 
on  laparotomy  for  g.  s.  wounds 
in  the  Manchurian  campaign, 
245 
stopping-power  of  Japanese  bul- 
let in  Russo-Japanese  War,  66 
the  wounds  by  shi'apnel  balls  in 
the  Russo-Japanese  War,  101 

IMakins,  ]Mr.,  on  the  difficulties  attend- 
ing abdominal  work  in  military 
practice,  245 
on  gunshot  wounds  of  the  head  in 
the  Boer  War,  160 

Magazine  breech-loading  rifles  with 
reduced  caliber,  6 

Malignant  pustule,  in  Russo-Japanese 
War,  by  Follenfant,  133 

Manteuifel,  gunshot  wounds  of  the 
heart,  223 

Matas,  Dr.  Rudolph,  statistics  of 
Charity  Hospital,  New  Or- 
leans, La.,  in  g.  s.  wounds  of 
abdomen,  250 

Match-lock,  3 

Medico-legal  phases  of  g.  s.  wounds,  367 

Meyer,  Dr.  Emil,  case  of  g.  s.  wounds  of 
larynx,  198 

Mines  and  torpedoes,  19 

Minie,  Captain,  French  Army,  5 

Minie's  rifle,  5 

Mortars,  2 

Mtiller  and  KoUer,  experiments  on 
varying  methods  of  treatment 
of  the  channel  of  g.  s.  wounds, 
148 

Multiple  wounds  by  reduced  caliber 
bullets,  369 

Musket-percussion,  4 

McAndrew,  Patrick H.,  Major,  M.  C,  U. 
S.  A.,  on  the  stopping-power 
of    U.  S.  A.  service  rifle,  67 


McPherson,  CoL,  W.  G.,  R.  A.  M.  C,  on 
tetanus  and  malignant  edema 
in  Russo-Japanese  War,  135 


N 


Xeate,  Dr.  John  S.,  on  the  use  of  iodine 

as  a  skin  disinfectant,  142 
Xeck,  wounds  of,  189 
air  passages,  197 
character   of,   in   Civil  War,  193 
complications  of,  192 
hemorrhage  in,  192 
jugular  veins,  193 
wounds  of  nerves,  194 
Xerves,  complete  division  of  individual 
nerves,  286 
concussion  of  individual,  284 
contusion  of  individual,  285 
partial    division   of   individual 

nerves,  286 
peripheral  injuries  to,  operation  for 
secondary  involvement  in,  288 
treatment  of,  287 


O 


CEttingen,    wounds    of  air  passages  in 
Manchurian  campaign,  198 


Pain,  as  a  symptom  oi  g.  s.  wound,  114 

Pancreas,  wounds  of,  265 

Parker,  Dr.  W.  E.,  on  fatality  of  ab- 
dominal wounds,  243 

Penis,  wounds  of,  271 

Pistol,  Colt's  automatic,  10 

Poisoned  wounds,  122-131 

the  character  of  toxic  substances 
on  the  implements  of  war,  132 

Poisoning  from  powder  gases  on  board 
naval  ships,  Stokes,  97 

Powder-brand,  a  medico-legal  question, 
369 

Powder-burn,  tattoo  or  stain  on  cloth- 
ing, a  mecUco-legal  question, 
371 


396 


INDEX 


Powder-marks     or    tattoo,    a    medico- 
legal question,  369 
Projectiles,  14 

characteristic  lesions  caused  by,  33 

classification  of,  14 

density  of,  29 

form  of,  29 

from  air-guns  and  Flobert  rifles,  16 

from      Gatling      and      automatic 

machine  guns,  22 
from  hand-weapons,  14 
from  shotguns,  15 
a  Medico-Legal  question,  372 
from  toy-pistols,  16 
motions  of,  23 
of  the  artillery-arms,    16 
the  motion  of  rotation  of,  26 
translation  of,  23 
Projectile,   was  it  jacketed  or   not,   a 

medico-legal  question,  380 
Probe,  Nelaton,  150 
Propellant,  compressed  atmospheric  air 
as,  14 


R 


Rectum,  wounds  of,  261 

Revolvers  and  pistols,  10 

Reyher,  Carl,  on  antiseptics  in  military 

surgery,  128 
Richardson,    on   the  average  mortality 
from    abdominal    wounds    in 
Charity  Hospital,   New  Orle- 
ans, La.,   before  the  days  of 
laparotomy,     250 
Rifles,  automatic,  32 
breech-loading,  6 
Flobert,  11 
Krag-Jorgensen,  6 
Lee-Speed  and  Lebel,  6 
magazine       breech-loaders       with 

reduced  caliber,  6 
maynard,  6 
military,  3-6 

evolution  of,  4 
Minie's,  principal  featm-es  of,  5 
of  different   combatant  armies,  in 
recent  wars,  51 


Rifles,  Sharp,  6 
Spencer,  6 
Springfield,  6 
target,  11 

United  States,  caliber     .30  model 
1903,  30 
ammunition  of  1906,  for,  30 
Roosevelt,     Theodore,     Col.,     on    the 
effects    of    pointed    bullet    in 
"African  Game  Trails,"  58 
Rotation  of  bullets,  26 


S 


Seaman,  Dr.  Louis,  Livingston,  on 
traumatic  aneurysm  in  Man- 
churian  campaign,  280 

Scrotum,  wounds  of,  273 

Senn,   Dr.   Nicholas,  hydrogen  gas  test 
in  intestinal  wounds,  241 
field  dressing,  141 

Septic  bullets  and  septic  powders,  128 

Shands,  Dr.  H.  R.,  statistics  of  operated 
and  non-operated  cases  of 
abdominal  wounds  in  Charity 
Hospital,  New  Orleans,  La., 
251 

Shell,  for  cannon,  16 

common,  wounds  by,  94 
Pom-Pom,  16 

wounds  by,  101 
wdth  case  shot,  canister,  or  shrap- 
nel, wounds  by,  101 

Shock,  local  and  constitutional  as  symp- 
toms of  g.  s.  wounds,  114 
treatment  of,  117 

Shotgun,  10 

Shotguns,  wounds  by,  a  medico-legal 
question,  372 

Shoulder-joint,  wounds  of,  298 

Shrapnel,  16 

Siegel,  Dr.  Ernest,  death  rate  in 
abdominal  wounds  subjected 
to  operation,  244 

Sigmoid  flexure,  wounds  of,  261 

Skull,  contusion  of,  157 

fracture  of  inner  table  alone,  158 
outer  table  alone,  157 


INDEX 


397 


Skull,  fracture  with  brain  injury,  158 
gutter  fractures  of,  160 
penetrating  fractures  of,  161 
perforating  fractures  of,  168 
removal  of  lodged  missiles  in,  184 
wounds  showing  explosive  effects 
in,  169 
without   lesion   of    cranial    con- 
tents, 156 
Small-arms,  evolution  of.  Table  No.  1, 

32 
Smokeless  powders,  12 
Spine,  wounds  of,  in  Anglo-Boer  War, 
200 
CivH  War,  200 
Franco-German  War,  200 
injin-ies  of,  treatment,  211 
Spleen,  wounds  of,  266 
Springfield  rifle,  old,  6 

new,  30 
Stevenson,  Col.  W.  F.,  R.  A.  M.  C, 
on   external    primary    hemor- 
rhage in  Boer  War,  119 
on  gunshot  wounds  of  the  head, 
158 
wounds  of  the  chest  in  the  Anglo- 
Boer  War,  216 
Stokes,  C.  F.,  surgeon-general  U.  S.  N., 
casualties    in    naval   combat, 
96 
Stomach,  wounds  of,  260 
Stopping-power  or  shock  effects  of  rifle 
buUets  in  recent  wars,  66 
of  reduced  caUber  buUet  (Lee-Met- 
ford)    in    Wizirestan    Chitral 
expeditions  1895,  66 
Strict,  on  the  influence  of  hematoma  in 
the   development   of   tetanus, 
136 
Synovitis  vibration,  from  g.  s.  wound, 

291 
Symptoms  of  gunshot  wounds,  114 


Tattooing  by  powder  gi-ains,  a  medico- 
legal question,  368 
Testicles,  wounds  of,  273 


Tetanus,  its  treatment,  138 
toy-pistol,  133 
3ind  toy-pistol  tetanus,  133 
in  war,  Table  No.  4,  134 
tendency    to,    augmented   by    the 
presence    of    hematomata    in 
wounds,  136 
Thirst,  as  a  symptom  of  g.  s.  wound,  114 
Thompson,    Col.    John    T.,    Ordnance 
Departrnent,  U.  S.  A.,  on  the 
stopping-power  of  pistols  and 
revolvers,  68 
Tibia  and  fibula,  g.  s.  fractin-es  of,  356 
treatment  by  amputation,  361 
conservation,  357 
Torpedoes,  19 
Toxic  substances,  vegetable,  animal  and 

mineral,  etc.,  133 
Toy-pistols,  16 

Toy-pistol  tetanus,   its  source  experi- 
mentally considered,  136 
Trajectory,  of  projectiles,  27 
danger  space  of,  etc.,  28 
of  different  kinds  of  rifles,  28 
Treatment  of  g.  s.  wounds,  140 

administration  of  food  and  stimu- 
lants, their  great  value  in,  151 
immediate  requirements  of,  140 
intermediate  requirements  of,  147 
remote,  153 

U 

United  States  rifle  (latest  model),  30 
Urethra,  wounds  of,  272 

V 

Velocities  and   energies  of  certain  bul- 
lets. Tables  No.  2,  3,  35,  70,  71 
Vericose,  aneurysm,  282 

W 

Wads  and  wadding,  a  medico-legal 
question,  372 

Wheel-lock  gun,  3 

White,  Dr.  C.  S.,  in  the  case  of  Nor- 
man Harris,  a  medico-legal 
question,  371 


398 


INDEX 


Wind  contusion,  96 

Winter,  Col.  F.  A.,  M.  C,  U.  S.  A.,  on 
the  stopping  power  of  the  U.S. 
Army  service  rifle,  68 
Woodbury,  Major,  M.  C,  U.  S.  A.,  on 
the  use  of  iodine  in    wound 
treatment,  142 
Wrist,  wounds  of,  307 
Wounds,  accidental,  suicidal  or  homi- 
cidal?   Medico-legal  questions, 
377 
by  hand-weapons,  33 
by  military  rifles  in  recent  wars,  51 
by   projectiles   from   the   artUlery 

arm,  94 
by  air-gun  projectiles.  111 
dangerous    to    life    (?)   a  medico- 
legal question,  374 
entrance  and  exit  by  large  caliber 
bullets,  33 
by  small  caliber  bullets,  52 
foreign  bodies  carried  in,  53 
from  blank  ammunition,  134 
from  Flobert  rifles,  110 
from  grenades,bombs  and  mines,  106 
from  pistols  and  revolvers  and  their 
shock    effects    experimentally 
considered,  68 
and  their  lesions,  68 
from    reduced    caliber    bullets    in 
Spanish-American   war,    com- 
pared to  those  inflicted  on  the 
cadaver,  41 


Wounds  from  shotguns,  109 

a  medical-legal  question,  372 

from  target-rifles,  109 

from  toy-pistols,  108 
Wound,  gunshot,  definition  of,  1 

how  was  it  inflicted,  a  medico- 
legal question,  276 

infection  in,  liability  of  practi- 
tioner in,  a  medico-1  e  g  a  1 
question,  375 

inflicted  before  or  after  death,  a 
medico-legal  question,  373 

multiple,  a  medico-legal  question, 
369 

of  entrance,  a  Medico-legal  ques- 
tion, 367 

of  head  by  reduced  caliber  bullets, 
56 

self-inflicted,  non-fatal,  a  medico- 
legal question,  379 

the  one  causing  death,  a  medico- 
legal question,  374 


X 


X-ray  apparatus,  field,  with  motorcycle 
engine,  385 
with  marine  engine,  386 
the   best   type   for   use   in   active 

campaign,  382 
use  of  in  active  campaign,  382 


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COLUMBIA  UiNIVERSrrV 
NEW  YORK 


DATE  DUE 

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